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Full text of "The institutional care of the insane in the United States and Canada"

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THE INSTITUTIONAL CARE 
OF THE INSANE 

IN THE 

UNITED STATES AND CANADA 



HENRY M. KURD, WILLIAM F. DREWRY, RICHARD DEWEY, 

CHARLES W. PILGRIM, G. ALDER BLUMER 

AND T. J. W. BURGESS 

EDITED BY 

HENRY M. HURD, M.D., LL.D. 

Emeritus Professor of Psychiatry, The Johns Hopkins University ; 

formerly Medical Superintendent of the Pontiac State 

Hospital; Secretary, The Johns Hopkins Hospital 



VOLUME I 



ILLUSTRATED 




THE JOHNS HOPKINS PRESS 

BALTIMORE, MD. 

1916 



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BALTIMOKK, Ml)., V. S. A. 



COMMITTEE OF THE AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION ON A HISTORY OF THE INSTITU- 
TIONAL CARE OF THE INSANE, 1908-1916. 

Henrv M. Hurd, M. D., LL. D., Chairman, 
Baltimore, Md. 

William Francis Drewry, M. D., 

Medical Superintendent Central State Hospital, 

Petersburg, Va. 

Richard Dewey, A. M., M. D., 

Formerly Medical Superintendent Kankakee State Hospital, 

Superintendent Milwaukee Sanitarium, 

Wauwatosa, Wis. 

Charles W. Pilgrim, M. D., 
Ex-President New York Commission in Lunacy, 
Medical Superintendent Hudson River State Hospital, 
Poughkeepsie, N. Y. 

G. Alder Blumer, M. D., L. R. C. P., 

Formerly Superintendent Utica State Hospital, 

Physician and Superintendent Butler Hospital, 

Providence, R. I. 

T. J. W. Burgess, M. D., F. R. S. C, 

Medical Superintendent Protestant Hospital, 

Professor of Mental Diseases McGill University, 

Montreal, Que. 



PREFACE. 

The preparation of the "History of the Institutional Care of the 
Insane," of which this forms the first volume, has been much 
delayed by an unexpected broadening of the original scope of the 
work. It was originally undertaken to give in detail histories of 
every institution in the United States and Canada with special 
reference to their foundation and development. Early in the 
course of the work, however, it became evident that such a com- 
pilation would not present in a concise and accessible form many 
important facts which were considered worthy of record for future 
use, and certain general chapters were added. The extended plan 
has involved a considerable increase in the labor of compiling the 
volumes and consequent delay in publication. The change of plan 
necessitated an extensive correspondence with state boards, state 
officers, superintendents of institutions, philanthropists and others 
in every part of the country; and from these various sources 
valuable information has been obtained which could not otherwise 
have been gathered. 

The thanks of the committee are due to Dr. Spencer L. Dawes, 
the Commissioner of Immigration ; to the New York State Hos- 
pital Commission ; to Dr. J. Montgomery Mosher ; to Mr. T. E. 
McGarr, formerly Secretary of the Lunacy Commission and later 
of the State Hospital Commission, all of Albany, N. Y. ; to 
Dr. T. Wood Clarke, of Utica, N. Y. ; to the Boards of Control 
of Minnesota, Illinois, Kansas, Iowa, Kentucky, Ohio, Nebraska, 
Colorado, Oregon and South Dakota ; to Dr. S. E. Smith, of 
Richmond, Ind., for invaluable assistance in connection with 
procuring histories of institutions in Indiana ; to the State Libra- 
rians of Oregon, Washington, New York, Pennsylvania and 
Maryland for information and access to original documents ; to 
Dr. Frank Woodbury, Secretary of the Pennsylvania Committee 
in Lunacy ; to Dr. C. Eugene Riggs, of St. Paul, for copies 
of the Minnesota statutes ; to the late Dr. H. A. Tomlinson, of St. 
T*eter State Hospital, Minn., for valuable documents ; to Dr. F. W. 
Hatch, of Sacramento, for many histories of the hospitals of 



VI PREFACE 

California ; to Drs. Owen Copp and C. E. Thompson, formerly 
of the Massachusetts Board of Insanity, for much assistance ; to 
Dr. L. Vernon Briggs, of the Massachusetts Board of Insanity, 
for kind co-operation and assistance ; to Dr. Geo. A. Zeller, of the 
Board of Administration in Illinois, for many favors ; to Dr. 
Charles P. Bancroft, of Concord, N. H., for valuable documents 
relating- to the early history of the hospitals in New Hampshire ; 
to Dr. Edward Cowles, of Boston, Mass., for material in refer- 
ence to the establishment of training schools for nurses, and also 
for the history of the development of laboratories in connection 
with insane hospitals ; to Dr. John B. Chapin, of Canandaigua, 
N. Y., for valuable historical notes upon the care of the chronic 
insane in New York, and for biographies ; to Dr. Charles W. 
Page, of Hartford, Conn., for the early history of the Hartford 
Retreat, and of the remarkable work of Dorothea L. Dix between 
the years 1840-1860; to Dr. B. D. Evans, of the New Jersey 
State Hospital at Morris Plains, for valuable copies of original 
documents relating to the care of the insane in New Jersey during 
the past century' ; to Dr. E. L. Bullard, of Rockville, Md., for an 
extended sketch of the so-called Wisconsin method of caring for 
the insane ; to Dr. J. W. Babcock, of Columbia, S. C, for permis- 
sion to use extracts from his " Public Charities of South Caro- 
lina," and for valuable assistance and suggestions ; and to Dr. 
W. W. Richardson, of Mercer, Pa., for painstaking assistance in 
gathering the histories of private institutions for the insane. Also 
to Mr. A. D. Eraser, Librarian of Parliament, Charlottetown, P. 
E. I., for sketch of the hospital and copies of early laws relating 
to its foundation ; to Dr. W. H. Hattie, formerly Medical Super- 
intendent of the Nova Scotia Hospital and now Inspector of 
Humane and Penal Institutions of Nova Scotia, for account of 
hospital and copies of early acts ; to Dr. David Young, formerly 
Medical Superintendent of Selkirk xA.sylum, Manitoba, for much 
valuable information regarding its early history ; to Dr. D. Low 
and Messrs. Storey and Van Egmond, for copies of acts and plans 
of the Battleford Hospital ; to Mr. Erank Scholes, Bursar of 
Ponoka Hospital, and Mr. A. M. Jeffers, architect, of Edmonton, 
for valuable information and plans of Ponoka Hospital, Alberta ; 
to Professor Hill-Tout, of Victoria, B. C, and Judge Howay, of 
New Westminster, B. C, for information regarding insanity 



PREFACE VU 

among the Indians of the Pacific Coast ; to Z. T. Wood, Assistant 
Commissioner R. N. W. Mounted PoHce, Regina, Sask., Law- 
rence Fortescue, Comptroller of the Force, Ottawa, Ont., and Dr. 
A. J. Gillis, Speaker Territorial Council, Dawson City, for informa- 
tion concerning the care of the insane in the Yukon and North- 
west Territories ; to Dr. C. K. Clarke, formerly Medical Superin- 
tendent of Kingston and Toronto Asylums, now Superintendent 
of the Toronto General Hospital, for sketches of those institu- 
tions ; to Dr. R. W. Bruce Smith and Edwin R. Rogers, Inspect- 
ors of Asylums, for information regarding Ontario institutions ; 
to the late Reuben G. Thwaites, Secretary of the Wisconsin State 
Historical Society and editor of " The Jesuit Relations," for 
information as to insanity among the eastern tribes of Indians ; 
to Dr. A. G. Doughty, Dominion Archivist, Ottawa, Ont., and his 
assistant, Mr. David W. Parker, Mr. Crawford Lindsay, chief 
English translator for Quebec Legislature, Mr. E. Z. Massicotte, 
Archivist of the District of Montreal, Miss M. Charlton, Libra- 
rian McGill University, and Miss M. L. Meiklejohn, Stanley Insti- 
tute, Ottawa, Ont., for researches relating to insanity during the 
period of the French regime in Canada, and copies of documents ; 
to Mr. H. P. Biggar, of Welwyn, England, for researches at the 
library of the Louvre, Paris, France; to Brother Superior Casi- 
mir, for an interesting sketch of the Retraite St. Benoit-Joseph ; 
to Dr. E. Tremblay for a sketch of L'Hospice Bale St. Paul and 
biographical notices of its founders ; to Lady Superioress, Mother 
M. A. Piche, of the Grey Nunnery, Montreal, for information 
regarding the early care of the insane in that institution ; to James 
Douglas, LL. D., New York City, and P. B. de Crevecoeur, 
Librarian, Eraser Institute, Montreal, thanks are specially due 
for the loan of rare works relating to the French regime in 
Canada ; to Dr. C. A. Porteous, Assistant Superintendent, Verdun 
Hospital, Montreal, for invaluable service in the revision of manu- 
scripts and in other ways ; to Mr. E. Dyonnet, Secretary Royal 
Canadian Academy of Arts, for assistance in the translation 
of old French documents ; to Dr. P. H. Bryce, Commissioner of 
Emigration, Ottawa, Ont., for many courtesies ; and to Dr. W. ]\I. 
English, of Hamilton, for valuable assistance. 

The obHgations of the committee to the individual superinten- 
dents of nearlv two hundred institutions in the United States and 



Vlll PREFACE 

Canada are very great ; in fact, without their co-operation it would 
have been impracticable to prepare any adequate history of the 
movements in the various states and provinces. 

It is evident from a careful study of all the material which has 
come into the hands of the committee that a gradual evolution has 
occurred in the care of the insane in America during the past half 
century, which bids fair to change materially the discouraging 
views as to the hopelessness of their cure which have prevailed for 
many years in the United States and Canada. 

The movement towards the prompt treatment of curable cases 
without the formality of legal commitment and under the same 
conditions as in admission to a hospital for general bodily disease, 
gives every hope that at an early day cases of recent attack may be 
received everywhere promptly, and that greatly increased numbers 
can be cured. Cases of a chronic nature are also now much more 
satisfactorily dealt with in institutions on the cottage plan, with out- 
lying colonies for the employment of patients, and have a cor- 
respondingly better opportunity to attain self-support. These 
movements promise to make material changes in future methods 
of caring for the insane. 

Special personal obligations are due by the Editor to R. G. 
Hazard, of Peace Dale, R. I., and to C. C. Harrison, of Phila- 
delphia, for generous assistance by loaning books not otherwise 
obtainable. His thanks are also due to Dysart McMullen, of Balti- 
more, for invaluable aid in the compilation of histories and the 
arrangement of material, and to Miss Mary Brinkley, his secretary, 
who has assisted in the correction of manuscripts and proof- 
reading. 



CONTENTS. 
SECTION CHAPTER I. page 

I. Introduction 5 

II. The Association of Medical Superintendents of American In- 
stitutions for the Insane, 1844-1893 11 

III. The American Medico-Psychological Association, 1893-1913... 53 

IV. The American Journal of Insanity 75 

CHAPTER II. 

I. Early and Colonial Care of the Insane 81 

II. The Era of Awakening 93 

CHAPTER III. 
I. Dorothea Lynde Dix and Her Work loi 

CHAPTER IV. 

I. Evolution of Institutional Care in the United States 139 

II. County Care of the Insane 144 

III. Chronic and Incurable Insane 147 

IV. The Colony System 156 

V. State Care 163 

VI. The Wisconsin System of County Care 168 

CHAPTER V. 

I. Evolution of the Administration of Hospitals I79 

II. Present Government of Institutions for the Insane 183 

HI. Methods of Investigation of Public Institutions 196 

IV. Development of Hospital Architecture 204 

CHAPTER VI. 

I. The Propositions 217 

II. Reforms in Caring for the Insane 223 

III. Medical Treatment of the Insane 230 

IV. Non-Medical Treatment of the Insane 234 

V. Emploj-ment for the Insane 242 

VI. Asylum Periodicals 250 

VII. Individual Treatment 254 

VIII. Experimental Removals 256 

IX. Origin of the Psychopathic Hospital in the United States 258 

X. State Psychopathic Hospital at the University of Michigan. ... 266 

XL Boston Psychopathic Hospital 276 

XII. Research Work in Hospitals 281 



X CONTENTS 

SECTION CHAPTER VIT. 

I. Training Schools for Nurses and the First School in McLean 

Hospital 289 

H. First Training School for Attendants at the Buffalo State Hos- 
pital (Asylum), 1883-1886 301 

CHAPTER Vni. 
I. Private Care of the Insane 313 

CHAPTER IX. 

I. Growth of the Law of Insanity 321 

II. Commitment of the Insane 331 

III. Conditions of Discharge 338 

IV. Admission of Voluntary Patients 344 

V. Care of the Criminal Insane 348 

CHAPTER X. 

I. Immigration and the Care of the Insane 355 

H. The Alien-Born in Relation to the Cost of State Care 362 

CHAPTER XI. 

I. Insanity among the Negroes 371 

II. Insanity among the North American Indians 381 

ill. Insanity among Indians in Soutli Dakota 386 

IV. The Chinese and Japanese Insane in the United States 393 

CHAPTER XII. 

I. Institutional Population 399 

II. Census of the Insane 411 

III. Feeble-Minded in Institutions 421 

CHAPTER XIII. 

I. Laws for the Commitment of the Insane in Canada 427 

II. Care of the Insane in Canada Previous to the Establishment 

of Provincial Institutions 446 

HI. Establishment of Provincial Institutions 454 

IV. System of Care in the Provinces of Canada, and Government 

and Inspection of Provincial Institutions 458 

V. The Contract System in the Province of Quebec 467 

VI. Immigration and the Care of the Insane in Canada 472 

VII. Census of the Insane in Canada 478 

VIII. The Chinese and Japanese in Institutions in British Columbia 

between the Years 1871 and 1913 480 

IX. Dorothea L. Dix and Canadian Institutions 481 



ILLUSTRATIONS. 

PAGE 

Eastern Lunatic Asylum, Williamsburg, Va., the Oldest State 

Institution Frontispiece 

Dr. William McClay Awl 12 

Dr. Luther V. Bell 14 

Dr. Amariah Brigham 16 

Dr. John S. Butler 20 

Dr. Nehemiah Cutter 24 

Dr. Pliny Earle 28 

Dr. John Minson Gait ^2 

Dr. Thomas Story Kirkbride 36 

Dr. Isaac Ray 38 

Dr. Charles Harrison Stedman 42 

Dr. Francis T. Stribling 44 

Dr. Samuel White 46 

Dr. Samuel Bayard Woodward 50 

The Eastern Lunatic Asylum, Williamsburg, Ya., about 1774 84 

New York Hospital (Lunatic Asylum), 1806-1821 86 

Lunatic Asylum — Ground Plan of Building to Left of General Hospital. 87 

Friends' Asylum, 1818 88 

Bloomingdale Asylum, 1821 90 

The Hartford Retreat, 1824 92 

Friends' Asylum, Frankford, 1828 94 

Maryland Hospital for the Insane, 1832 96 

Friends' Asylum, 1835 106 

Brattleboro Retreat (Vermont Asylum), 1836 no 

Western Virginia Lunatic Asylum, 1838 120 

Brattleboro Retreat (Vermont Asylum) , 1844 130 

Butler Hospital, Providence, R. I., 1848 140 

New York State Lunatic Asylum, about 1850 152 

Provincial Lunatic Asylum, Toronto, Ont., 1850, North View 428 

Provincial Lunatic Asylum, Toronto, Ont., 1850, South View 432 



PART I 

GENERAL HISTORY IN THE 
UNITED STATES 



CHAPTER I 
THE ORGANIZED ACTIVITIES OF ALIENISTS 







I. 

INTRODUCTION. 

At the meeting of the American Medico-Psychological Associa- 
tion in Baltimore in 1897, Dr. Theophilus O. Powell, superinten- 
dent of the Georgia Sanitarium at ]\Iilledgeville, Ga., at that time 
president of the Association, presented as a presidential address 
a sketch of psychiatr}^ in the Southern states, which was received 
with marked attention by all the members present. 

In the following year, at the meeting of the Association in St. 
Louis, a paper was presented from Dr. J. W. Babcock, of Colum- 
bia, S. C, who was absent, entitled " A History of the Insane in 
America, Shall the Association Have one Prepared?" Unfor- 
tunately no copy of this paper can be found nor any record of the 
disposition made of it. 

Although no record was made, it is evident that a committee on a 
history of the Association was appointed, because in the following 
year in New York Dr. Babcock recommended that the committee 
appointed the previous year be dropped, and that the whole matter 
be referred to the Council with power to act. In the discussion 
which followed appropriate reference was made to the philan- 
thropic work of those who had labored to develop insane hospitals 
in the different sections of the country, and the consensus of 
opinion was general that the Council of the Association should 
take charge of the preparation and publication of an adequate 
account of their work in behalf of the insane during the previous 
century and of accompanying biographical sketches of the men 
who had been concerned in the movement. It was also agreed that 
the Council should employ an historian to compile whatever 
material was obtained for such history. These suggestions were 
adopted and the Council was empowered to employ an historian 
and to do everything required to advance the work. 

The project, however, slumbered until the Cincinnati meeting in 
1908, when the matter was again considered and a committee of 
five was authorized to assume charge of the project and to report 
at the next meeting of the Association. The president. Dr. Charles 
P. Bancroft, of Concord, N. H., appointed as such committee. 



6 INSTITUTIONAL CARE OF THE INSANE 

Henry M. Hurd, chairman, Baltimore, Md. ; William F. Drewry, 
Petersburg, Va. ; Richard Dewey, Wauwatosa, Wis. ; Charles W. 
Pilgrim, Potighkeepsie, X. Y. ; G. Alder Blumer, Providence, R. 
I. ; and T. J. W. Burgess, Montreal, Canada, to organize the work. 

In 1910 at the meeting of the Association in Washington, the 
first report of the committee was read, and a plan of action was 
outlined. The Association adopted the plan and appropriated a 
continuing annual sum of $300 to be used as a publication fund. 

In the summer of 191 1 a systematic effort was made to interest 
all members of the Association in the project and to secure from 
every section of the United States and Canada adequate co-oper- 
ation in the effort to collect historical material. 

The older states like Massachusetts, Rhode Island, Connecticut, 
New York, Pennsylvania, Virginia and South Carolina were found 
to have fairly complete records of the earlier institutions. The 
Hartford Retreat had served as a model for nearly all institutions 
in New England for patients of the private class. The Worcester 
State Hospital in Massachusetts, the Utica State Hospital in New 
York, and the Pennsylvania Hospital for the Insane in Philadel- 
phia had in like manner influenced to a marked degree the erection 
of similar institutions in all sections of the United States. The 
Worcester Hospital had many imitators in New England and 
Canada ; while the Utica State Hospital and the Pennsylvania 
Hospital had been generally copied by new institutions in the 
South and West ; the former for its organization and mode of 
management, and the latter as furnishing an example of substan- 
tial, durable and inexpensive construction. 

Several publications were found which gave interesting details 
respecting some earlier institutions. Among these were the reports 
of the Worcester State Hospital and of the Brattleboro Retreat, 
especially the volume known as the " Annals of the Vermont Asy- 
lum," prepared by Dr. Joseph Draper on the occasion of the fiftieth 
anniversary of the founding of the Retreat. The reports of the 
McLean Asylum, the gathered papers of the New Hampshire State 
Hospital, at Concord, the history of the Bloomingdale Hospital by 
Earle and continued by Lyon, J. B. Chapin's portion of Morton's 
History of the Pennsylvania Hospital, Babcock's History of the 
Charities of .South Carolina, the Report of the Worcester State 
Hospital for 1828, the Centennial Report of the Williamsburg, Va., 



INTRODUCTION 7 

Hospital, and Burgess' paper before the Royal Society of Canada, 
were also of great value. 

The committee found it difficult to get any adequate or satis- 
factory account of the condition of the insane in many of the states 
prior to the establishment of state institutions. The conclusion is 
forced upon the student of history that the insane as a class at that 
period were universally neglected, and little or no effort was made 
to provide anything beyond shelter for them, and sometimes even 
shelter was lacking. It is also saddening to find that the optimism 
of the earlier philanthropic movements which culminated in the 
Hartford Retreat, the Worcester State Hospital, the Brattleboro 
Retreat, the Utica State Hospital and other kindred institutions 
was doomed to disappointment. These movements owed their 
origin largely to the mistaken idea that insanity was a curable dis- 
ease and that all forms of mental disease, if taken at an early stage, 
could be quickly cured. Hence the erection of a single institution 
in states like New York, New Jersey, Pennsylvania, Ohio, Indiana 
and other Western and Southern states, which soon proved to be 
wholly inadequate to meet the needs of such rapidly growing com- 
monwealths. Consequently the condition of the insane in these 
states soon became as bad as before any institution had been built ; 
although unquestionably the erection of institutions improved the 
standard of public care, and did much to keep before the people 
the need of increased care and further provision. Whether pioneer 
states with scanty resources, imperfect means of communication 
and a general indifference to humanitarian calls could have made 
more speedy or more liberal provision for the insane, remains a 
question. All good citizens were struggling for a living and no 
community had any surplus funds to undertake a work which 
involved the erection of buildings and the elaborate administrative 
and professional machinery required for adequate care and proper 
treatment. For many reasons it has seemed advisable to trace the 
history of these early pioneer institutions with care and to give 
comparatively full details as to their organization, hopes, successes 
and failures. 

In each state there arose public-spirited, self-sacrificing, devoted 
men, who labored faithfully and zealously with scanty resources 
to develop an interest in the proper care of the insane. In many 
pioneer states their efforts, however, would have failed had it not 



8 INSTITUTIONAL CARE OF THE INSANE 

been for the wonderful initiative of Dorothea L. Dix, who year 
after year visited the newer states to urge the need of better care 
for the dependent and helpless. The committee accordingly feels 
that it has been justified in devoting a long chapter to her work, 
because when viewed after the lapse of more than fifty years it 
seems more faithful and ef^cient than that of any other person 
during the nineteenth century. 

The committee early in its work found it prerequisite to suc- 
cessful work to divide the United States and Canada into districts 
and as far as possible to ask the individual members to be responsi- 
ble for these districts. Dr. Blumer assumed the responsibility of 
New England; Dr. Pilgrim, of New York, New Jersey and Penn- 
sylvania ; Dr. Dewey of Wisconsin and Illinois ; Dr. Drewry of 
the Southern states ; Dr. Burgess undertook the collection of his- 
tories from Canada ; and the chairman that of the other states in 
addition to the general editorial work. 

The scheme of the enterprise has grown in the hands of the com- 
mittee. Besides securing historical data covering the early and 
colonial times, it has been thought wise to trace the evolution of 
laws of commitment in each of the United States and the provinces 
of Canada. This has required a large amount of correspondence 
and investigation. In fact had it not been for the publication by 
Dr. Salmon, formerly of the Public Health and Marine Hospital 
Service, now detached for service in connection with the Society of 
Mental Hygiene, of a compilation of the laws of each state in the 
Union, it would have been difficult to present a satisfactory abstract 
of the laws of commitment. The Canadian laws show less diver- 
sity, and the task of collecting them has been less onerous. 

It also seemed desirable to treat of different methods of care 
in the various states. This has led the committee to include early 
care by counties and townships or charitable institutions, prior to 
any state care. Chapters on county care of the insane have been 
prepared ; also on the care of chronic and acute cases ; on the Wis- 
consin and Pennsylvania systems where institutions have been sub- 
sidized by the state ; and finally on state care. 

Chapters on the administration of hospitals, the immigration 
problem and the care of the Indian, colored and foreign insane 
have been inserted. 



INTRODUCTION 9 

Under the heading, Treatment of the Insane, considerable pains 
have been taken to give adequate sketches of the estabhshment of 
training schools for nurses in connection with hospitals ; the 
methods of government of hospitals ; reforms in methods of caring 
for the insane; and the development of hospital architecture. 

The treatment of the insane by non-medicinal means, such as 
amusements, industries, etc., and the influence of experimental re- 
movals and individual treatment, have been carefully considered. 

The long contest which occurred in the Medico-Psychological 
Association over the so-called " propositions " has received due 
attention. It is difificult at the present time to conceive why so 
much feeling was engendered in the discussion which attended the 
abrogation of the famous " propositions " adopted 20 years before. 
The chapter is of special interest because it shows how much care- 
ful thought was given by men interested in the care of the insane 
to all questions affecting them and their conscientious desire to do 
what was right. 

There are chapters also on the admission of voluntary patients 
and the care of the criminal insane. 

In the histories of individual states it has been thought advisable 
to present the states in alphabetical order, and to give with each a 
careful account of early efforts in behalf of the insane, and the 
rapid growth of a philanthropic movement for better care from 
1840 to i860. Following general statements in regard to each 
state, histories are given of institutions for the insane of ever)' 
character, with an account of their organization, growth and 
development. These histories include movements which have taken 
place within states to adopt new systems of treatment, new methods 
of care, and new methods of governing institutions. 

As might be expected, the histories presented by the institutions 
of different states have varied much. Some have been written 
with extreme care, others have been hastily put together and pre- 
sent an inadequate picture of the actual condition of the institution. 
The committee in all such cases has made an effort to procure addi- 
tional material. It is much to be regretted that it has frequently 
been difficult to secure many necessary details. In some states, 
owing to the rapid changes of officers which have followed changes 
in political control, important details have been lacking, because no 
adequate records have been kept. In one state it was impossible to 



10 INSTITUTIONAL CARE OF THE INSANE 

secure the nani'^s of the men who had acted as superintendents of 
an institution ; in another, one of the oldest institutions which had 
an honorable early career was destitute of any details as to its 
origin or later development. It is hoped that the publication even 
of these manifestly imperfect histories may in the future stimulate 
all institutions to keep careful records of the growth and develop- 
ment of their institutions and the name, date of appointment, term 
of office and period of service of each officer. 

Careful efforts have been made to supply adequate biographical 
details concerning the men who have acted as officers of institu- 
tions, or who have been efficient in promoting the welfare of the 
insane, either as trustees, state officers, or philanthropists. The 
number of such biographies is upwards of 300, and many more 
ought to be collected. The committee is aware that these biog- 
raphies are not uniform in their mode of presentation ; many have 
been taken from biographical notices prepared by friends ; a large 
number from medical journals, and other sources. The biographies 
of many excellent men are far too brief because fuller details have 
not been obtainable. It is to be regretted that all could not be 
treated alike ; it has seemed best to supply the essential facts about 
every man and to give in addition whenever possible the estimate of 
his character which had been formed by his friends who knew him 
best. 



II. 

ASSOCIATION OF MEDICAL SUPERINTENDENTS OF 

AMERICAN INSTITUTIONS FOR THE 

INSANE, 1844-1893. 

The Association as appears from the records was estabHshed in 
consequence of a casual meeting between Dr. Samuel B. Wood- 
ward, of Worcester, Mass., and Dr. F. T. Stribling, of Staunton, 
Va., both then superintendents of institutions for the insane. As 
a result of their conversation it was decided to hold the first meet- 
ing of the proposed Association on the i6th of October, 1844, at 
Jones' Hotel in the City of Philadelphia.' 

On this occasion there were present : 

Dr. Samuel B. Woodward, of Worcester State Hospital, Massa- 
chusetts. 

Dr. Isaac Ray, of the Maine State Hospital for the Insane, 
Augusta, Me., and subsequently of Butler Hospital, Providence, 
R.I. 

Dr. Luther V. Bell, Superintendent of McLean Asylum at 
Somerville, Mass. 

Dr. Charles H. Stedman, of the Boston Lunatic Asylum. 

Dr. John S. Butler, then of the Boston Lunatic Asylum, but later 
and for 30 years Superintendent of the Hartford Retreat, Con- 
necticut. 

Dr. Amariah Brigham, formerly of the Hartford Retreat, but 
after 1843 Superintendent of the State Lunatic Asylum, Utica, 
N. Y. 

^ The house in which Dr. K. lived, and which was my home for 27 years, 
is still interesting not only for its age but for its connection with the forma- 
tion of our Association. On the 15th of October, 1844, on invitation of Dr. 
Kirkbride, after some informal correspondence, the "original 13" assembled 
in the parlor in the evening and formulated some plan of an organization, 
which was confirmed on the next day, the i6th of October, at a formal 
meeting held at " Jones' Hotel," which was in Chestnut street above Sixth. 
This " mansion " is still standing and is the residence of the physician. It 
is the birth-place of the Association and an interesting specimen of the 
house architecture of that early period, having been erected prior to the 
year 1800, and a view of the house with its associations is worthy of pres- 
ervation. — Extract from letter of Dr. J. B. Chapin. 

3 



12 INSTITUTIONAL CARE OF THE INSANE 

Dr. Pliny Earle, Superintendent of Bloomingdale Asylum, New 
York City. 

Dr. T. S. Kirkbride, Superintendent of the Pennsylvania Hos- 
pital, Philadelphia, Pa. 

Dr. Wm. M. Awl, Superintendent of the State Hospital at 
Columbus, Ohio. 

Dr. F. T. Stribling, Superintendent of the Western Hospital of 
X'irginia, at Staunton, Va. 

Dr. John M. Gait, Superintendent of the Eastern Lunatic Asy- 
lum at Williamsburg, Va. 

Dr. Nehemiah Cutter, for many years in charge of a private 
institution at Pepperell, Mass. 

Dr. Samuel White, Superintendent of a private institution at 
Hudson, N. Y. 

Of these men, Brigham, Stedman, Ray, Butler and Earle were 
all natives of Massachusetts ; Kirkbride and Awl of Pennsylvania ; 
Woodward and White of Connecticut ; Bell and Cutter of New 
Hampshire ; and Stribling and Gait of \'irginia. Two of the num- 
ber, Cutter and White, were in charge of small institutions for 
private patients, the former in Massachusetts and the latter in 
New York. Six of them, namely, Woodward, Stribling, Brigham, 
Ray, Awl and Gait, were in charge of state institutions, while 
Earle, Kirkbride, Butler and Bell were in charge of endowed 
incorporated institutions under more or less public control. 

Dr. Stedman alone was in charge of a municipal institution, 
namely, the Boston Lunatic Hospital, which was then under the 
control of the City of Boston. Several others, however, had gained 
experience in both corporate and state institutions. Woodward at 
an early day had been active in the establishment of the Hartford 
Retreat and had acted as one of its visitors before going to Wor- 
cester, while Brigham and Ray had each been connected with 
state and corporate institutions. Dr. Earle subsequently became 
superintendent of the State Hospital at Northampton, Mass. Dr. 
Butler, before becoming superintendent of the Hartford Retreat, 
had been for three years superintendent of the Boston Lunatic 
Hospital. They were all men of unusual ability and among the 13 
there were at least three groups, each of recognized excellence. 

In the planning and construction of buildings and the organiza- 
tion of institutions, Dr. Kirkbride was unquestionably pre-eminent. 




DR. WILLIAM McCLAV AWL. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 1 3 

Through his efforts the famous " propositions " governing the con- 
struction of buildings for the insane were formulated and brought 
to the attention of the Association. He also framed the " proposi- 
tions " which were subsequently adopted as to the organization 
and government of institutions. 

Dr. Ray early turned his attention to medico-legal questions and 
excelled in the knowledge of law as applied to insanity. He had 
already written a book upon the " Medical Jurisprudence of Insan- 
ity," which had attracted wide attention. He had also written upon 
insanity and allied subjects. He possessed unusual clearness as 
a writer and was well grounded in legal principles, many of which 
were destined later to become formulated into laws. 

Ray, Earle, Bell, Brigham, Butler and Cialt, all of them in fact, 
wrote with facility, force and clearness and were well fitted to the 
task of impressing their ideas upon the medical profession in the 
United States, though as a purely literary man of wide culture and 
scholarly aims, it is probable that Dr. Gait took the first place. He 
had an excellent knowledge of ancient and modern languages ; he 
was reputed to be able to read Arabic, and had also written a work 
upon the treatment of insanity. 

Dr. Brigham had written several small volumes, one on " Influ- 
ence of Mental Cultivation on Health," another on the " Influence 
of Religion on the Health and Physical \\'elfare of Mankind," 
which had been widely circulated, and a third entitled an " Inquiry 
Concerning the Diseases and Functions of the Brain, the Spinal 
Cord and the Nerves." 

Those most eminent in the art of medicine were probably Brig- 
ham, Bell, Woodward and Earle. In Brigham's early reports occur 
interesting painstaking and enlightening observations respecting 
mental diseases. Dr. Earle's literary and professional activity con- 
tinued for many years, well-nigh to the day of his death. Early 
in his career he traveled abroad and gave to the American Journal 
of Insanity the results of his observations of foreign institutions. 
The idea, inherited by the medical profession from Rush, that 
blood letting was essential to the successful treatment of insanity 
was opposed by him with great vigor, and it was largely through 
his efforts that the practice was discontinued. Bell had written 
upon hygienic and medical subjects, but he will probably be best 
known to fame by his painstaking and careful observations on a 
form of acute excitement now known as " Bell's disease." 



14 INSTITUTIONAL CARE OF THE INSANE 

Dr. Butler was a ready writer and did much to bring" a knowl- 
edge of the proper and individual treatment of the insane to the 
notice of those engaged in their treatment. Subsequently, for 
many years before his death, he was a member of the State Board 
of Health of Connecticut, to which he contributed valuable papers 
upon hygienic subjects. 

All, with possibly the exception of Dr. Gait, had been trained in 
the hard school of poverty. They owed their eminence to their 
own energy, industry and talents and had derived little benefit from 
wealth or position, though Dr. Bell, it is true, was the son of a man 
who had been Governor of New Hampshire, then an undeveloped 
state, as well as Chief Justice and United States Senator. Two of 
the number, at least, Earle and Kirkbride, were Quakers, and all 
seemed to have been men of unusually strong religious convictions 
and belief, as shown by their writings. 

It is interesting to notice the comparative youthfulness of most 
of these men at the time they assumed the care of the insane : Gait 
was 22; Stribling, 26; Bell, 30; Earle, 31 ; Kirkbride, 32; Ray, 
34 ; Cutter, 35 ; Butler, 36 ; Stedman, 37 ; Awl, 39 ; Brigham, 42 ; 
Woodward, 45 ; and White, 53. 

Many of them lived to old age, Kirkbride, Stribling, Earle, Ray, 
Butler, Awl and Cutter more than filling out their allotted three 
score years and ten, but Gait, Brigham and Bell died compara- 
tively young; Gait in consequence of worry and distress incident 
to the Civil War; Brigham of grief, over-work and unhygienic 
conditions in his institution ; and Bell of exposure during the Civil 
War. 

It is evident that New England ideas prevailed largely in the 
organization and management of the different institutions which 
these men represented, ideas which entailed great economy both 
in management and construction and induced a certain rigidity of 
mold which unquestionably hampered their development. It must 
not be forgotten, however, that the country was then new and 
most of it was under pioneer conditions, the legal machinery of 
every state was crude, labor was scarce, markets uncertain, legis- 
latures economical, and every condition of life favorable to thrift 
and even parsimony. 

The original object of the Association was to meet for con- 
ference respecting problems which arose in the care of the insane. 




DR. LUTHER V. BELL. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 1 5 

or in the conduct of institutions. The members had Httle thought 
of organizing an association for higher medicine or the prosecu- 
tion of scientific work and, as a consequence, the earher meetings 
were largely occupied with the relation of experiences and mutual 
interchange of opinions. Committees were promptly appointed to 
report upon matters of practical importance; for example, at the 
second meeting, Brigham reported on the ]\Ioral Treatment of 
Insanity; Woodward on the Medical Treatment of Insanity; Bell 
on Restraint and Restraining Apparatus ; Awl on the Construction 
of Hospitals; Butler on the Jurisprudence of Insanity; Kirkbride 
on the Organization of Hospitals ; Earle on the Statistics of 
Insanity; Brigham on Asylums for Idiots and the Demented; 
Butler on Chapels and Chaplains ; Kirkbride on Post-mortem Ex- 
aminations ; Gait on Asylums for the Colored Insane ; Brigham on 
Proper Provision for Insane Prisoners ; and Bell on the Construc- 
tion of Hospitals for the Insane, a list of subjects which bears wit- 
ness to the wide field of activities covered by the Association and 
shows how alive its members were to the practical questions then 
pressing upon them for consideration. 

As all were picked men, no special qualifications or recommenda- 
tions on the part of future members seem to have been thought 
necessary to secure admission to the Association ; in fact, it was 
customary for many years to receive as members such men as hap- 
pened to be appointed superintendents of institutions for the insane 
throughout the United States and Canada. Eventually, when 
superintendents of institutions began to be selected according to 
the political tenets which they held and were more or less con- 
stantly changed in order to keep pace with political changes in 
several doubtful states, the high morale and intense feeling of 
devotion to the interests of the insane, which characterized the 
Association in its early days, became distinctly lowered and dis- 
cordant elements crept in. It is interesting to notice, however, 
that for many years the Association maintained a high standard of 
efificiency on the part of its members and considered questions 
which at that time were new and of the utmost practical impor- 
tance in the development of the public care of the insane. Such 
subjects as these, for example, were discussed : 

" The Treatment of Incurables." " The Relation Between 
Phrenology and Insanity," phrenology being at this time regarded 



l6 INSTITUTIONAL CAKE OF THE INSANE 

as an exact science and its most prominent expounders, Gall and 
Spurzhcim. being considered competent to give correct views as 
to the classification of insanity. " The Admission of Visitors, 
Visits to Patients and Correspondence wath their Friends." " The 
A^alue of DifTerent Kinds of Labor for the Insane."' " The Proper 
Number of Patients in One Institution." "The Utility of Night 
Attendants and the Propriety of Not Locking Doors of Patients' 
Rooms During the Night." " The Advantages and Disadvantages 
of Cottages Adjacent to the Institution." " The Relative Value of 
Ditiferent Kinds of Fuel for Heating the Hospital." 

These and many other practical questions were reported upon 
and discussed with conscientious care by the dififerent members. 

As already stated the first meeting of medical superintendents 
and physicians of hospitals and asylums for the insane convened 
at Jones' Hotel in Philadelphia, on the i6th of October, 1844, and 
after a session of two days adjourned to meet in the City of Wash- 
ington on the second Monday of May, 1846. The title of the 
Association as agreed upon was " The Association of Medical 
Superintendents of American Institutions for the Insane," and it 
was resolved " that the medical superintendents of the various 
incorporated or other legally constituted institutions for the insane 
now existing or which may be commenced prior to the next meet- 
ing, be and hereby are elected members of this Association." This 
seems to indicate that the Association was planned to be an organi- 
zation for consultation and discussion upon matters referring to 
the conduct of institutions rather than a scientific society for the 
advancement of psychiatry. Thirteen persons were present. 

The second meeting of the Association was held at Coleman's 
Hotel, in the City of Washington, on the nth of May, 1846. Dr. 
Samuel B. Woodward was elected president and Dr. Thomas S. 
Kirkbride was made secretary. The members in attendance at 
the previous meeting were largely present, there being only three 
absentees. One member. Dr. White, had died. Twenty-one mem- 
bers were present, there being several new members. 

Reports were received from the various committees appointed 
at the previous meeting and much discussion was held as to the 
plans of the Association. A resolution was adopted requesting that 
autopsies be made in all cases of insanity which had terminated in 
death, and that the results be reported at the next meeting of the 
Association. 




DR. AMARIAH BRIGHAM. 



ASSOCIATION OF MEDICAL SUPERIXTENDEXTS I7 

It was also decided that each member of the Association be 
requested to ascertain the facts and circumstances connected with 
each case of suicide occurrin^;^ in the state of his residence during 
the entire year of 1847, ^"cl to forward to the chairman of the 
Committee on Suicide an abstract of the same. 

A committee of two was appointed to prepare the transactions 
of the Association for publication in a collected form, or such parts 
of the same as it might deem expedient to publish. The secretary 
was further directed to publish abstracts of the proceedings in the 
American Journal of Insanity, The American Journal of the Medi- 
cal Sciences, and the New York Journal of Medicine. The value 
of publicity seems to have been generally recognized. 

The third meeting of the Association was held in the City of 
New York at the Astor House, on the 8th of May, 1848, under the 
presidency of Dr. W. M. Awl, of Ohio. Twenty superintendents 
of institutions were present. Elevations and ground plans of 
several institutions in the United States and Canada were placed 
on the walls for examination by members of the Association, and 
a variety of carving and fancy work done by the patients in the 
New York State Lunatic Asylum was exhibited. It is interesting 
to note further that ingenious buckles and other improved features 
of restraining apparatus were also exhibited. This would seem to 
indicate that the use of restraining apparatus was not wholly un- 
known. 

Written reports on the following subjects, after a full discus- 
sion, were accepted and laid upon the table : By Dr. Rockwell, 
" On the Comparative \'alue of the Labor of Patients and the Best 
Means of Employment in the Winter." By Dr. Kirkbride, " On 
the Advantages and Disadvantages of Cottages for Wealthy Per- 
sons Adjacent to Hospitals for the Insane." By Dr. Bates, " On 
the Relative Value of Different Kinds of Fuels for Heating Hos- 
pitals." By Dr. McFarland, " On the ^lost Economical ]\Iethod of 
Treating the Insane of the Poorer Classes." By Dr. Gait, " On 
Reading, Recreation and Amusements for the Insane." By Dr. 
Cutter, " On the Use of Tobacco and Its Effects on the Insane." 
A paper was also read by Dr. James ]\Iacdonald, " On Diseases 
and Causes of Death Among the Insane." Another by Dr. Earle, 
" On Statistics of Insanity," and the third by Dr. Stedman, " On 
the Treatment of Delirium Tremens by Inhalation of Ether." 



l8 INSTITUTIONAL CARE OF THE INSANE 

It is of interest to notice that the members of the Association 
had the courage of their convictions, and after they had visited 
and thoroughly examined the asylum on Blackwell's Island, they 
passed a series of resolutions regarding the treatment of the insane 
there, from which the following is extracted : 

It would be far more grateful to their feelings could they leave this, as 
they do the other asylums for the insane, in this vicinity, which they have 
also examined, in silent but respectful regard at seeing great objects properly 
accomplished. In so doing, they would escape the unpleasant necessity of 
instituting painful criticisms in the face of personal civilities, and the hazard 
of being considered, by the unreflecting, as guilty of improper interference 
in the affairs of a community not their own. 

Devoted as most of them have been for many long years of their lives to 
the care and restoration of those deprived of reason ; familiar, as many of 
them have been from personal examination, with the condition of this class 
of sufferers under the varying circumstances of the different communities 
of the old and new world; looking upon themselves while citizens of widely 
separated states, yet common denizens of that republic of humanity that 
knows no state lines, they willingly venture all risk of being misunderstood 
and misrepresented, when they declare their conviction, that the arrange- 
ments for the three or four hundred pauper lunatics of this city are far in 
the rear of the age; of the standard of other regions equally advanced in 
civilization and refinement; of the imperative demands of common justice, 
humanity and respect due to the image of a common Father, however much 
disfigured and changed. 

They would, therefore, appeal to the authorities of this mighty and 
opulent metropolis of the western world, to sustain the honor of their 
leading position ; to those who must feel that they and their children have 
no immunity against loss of property, of friends, and of reason, to those 
who recognize the obligations imposed by their own elevation and success 
to protect the friendless and miserable, to interpose their determined resolu- 
tion no longer to permit the Empire City to stand below the demands of 
the age, in the justice, humanity, yea. in the common decency, with which 
those guilty of no crime, but stricken by the hand of Providence in the loss 
of reason, are treated. Suffer no longer, we implore you, those whose 
sensibilities are not extinguished, but may even be more intense, whose 
honest self-respect and pride of character are not always permanently 
obliterated, whose return to society and to usefulness is not elsewhere the 
rare exception, but the expected result; to be abandoned to the tender 
mercies of thieves and prostitutes, who are, to a considerable extent, the 
associates and keepers of this helpless charge, and clothed with all the 
delegated authority and influence which such a relation necessarily implies. 

This Association has neither the means nor the disposition to inquire 
why the pauper lunatics of this community should have been allowed to 
lapse into that depth of degradation and neglect, of which it would be dif- 
ficult elsewhere to find a parallel. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS IQ 

Enough is it for them to know, that such is the fact, notwithstanding plans 
and designs for every modern arcliitectural requirement, as well as curative 
and ameliorating appliances, have been long in the hands, and subjected to 
the favorable criticism and comparison of those elsewhere charged with 
the same duties, and have been recognized as fully adequate to meet the 
exigency. 

They have examined the recent report of the medical visitors, and con- 
clude with them fully in their conclusions, as to the necessity of an entire 
change in the system, in the impossibility of doing all that justice, humanity 
and a sound economy require for the insane, except at a cost of money suf- 
ficient to provide faithful, competent, respectable assistants or keepers and 
adequate means of classification, inspection, labor, amusement, ventilation 
and cleanliness. They believe a just economy requires the abandonment, or 
conversion to collateral uses merely, of those miserable apologies for insane 
hospitals, known as the old and the new madhouses ; and if the Island is 
retained as a site for these institutions the original design, fully satisfactory 
in its great outlines and principles, should at once he carried out to com- 
pletion. 

The superintendents also made the important statement by reso- 
lution " that any attempt in any part of this country to select medi- 
cal superintendents through political bias be deprecated by the 
Association as a dangerous departure from that sound rule which 
should govern each appointing power, of seeking the best men 
irrespective of every other consideration." 

The fourth meeting of the Association was held in the City of 
Utica, N. Y., at Churchill's Hotel, on the 21st of May, 1849. The 
attendance was not large, less than 20 members being present, sev- 
eral members of the board of managers of the lunatic asylum at 
Utica were also present, and, for the first time, a superintendent 
from Canada was in attendance. 

Dr. Buttolph, of New Jersey, read a paper on the relation of 
phrenology to insanty, which elicited considerable discussion and 
indicated that the majority of the members did not believe that 
phrenology had a scientific basis. 

Dr. Bell, of New Hampshire, read a report " On a Certain Form 
of Disease Resembling Some Advanced Stages of Mania of the 
Delirium of Typhoid Fever, or of Cerebral Inflammation, but 
which may Perhaps Constitute a Hitherto Unrecognized and 
Undescribed Malady," to which later the name of Bell's disease 
has been given. The paper apparently did not receive the con- 
sideration and discussion which it deserved. It was probably the 
first original contribution of the Association to psychiatry. 



20 INSTITUTIONAL CARE OF THE INSANE 

The fifth meeting of the Association was held at the Tremont 
House, in Boston, on June i8, 1850. There were 28 members pres- 
ent, a portion of whom were members of boards of trustees of 
institutions for the insane. The most important part of the pro- 
ceedings was the presentation of a report by Dr. Ray on the proj- 
ect of a law regulating the legal relations of the insane. The 
report does not seem to have been discussed at this meeting and 
subsequently was recommitted to a committee to be considered at 
the next meeting. 

Dr. Bell asked in view of a paper which he had read the previous 
year on a peculiar form of mental disease, now generally known as 
" Bell's disease," that a committee be appointed to visit a case 
under treatment at the McLean Hospital and to report the results 
of their observation. A committee consisting of Drs. Awl, Kirk- 
bride and Fremont, of Beauport Asylum, Quebec, visited the 
patient and reported later that it was a well-marked case of " Bell's 
disease," and that " it is frequently met with in large cities where 
cases manifesting mental disturbance are promptly sent to a hos- 
pital for the insane." 

A resolution was passed expressive of the deep interest and 
unqualified sanction of the Association in the magnificent project 
at that time 1)eing urged on the consideration of Congress by Miss 
Dorothea Dix, to grant a portion of the public domain for the 
endowment of public charity throughout the country. 

The sixth meeting occurred at Philadelphia, on the 19th of May, 
1 85 1. Twenty-two superintendents and trustees were present. Dr. 
Awl resigned as president and was succeeded by Dr. Luther V. 
Bell. 

A resolution was adopted that the members of the Association 
report at the next meeting all the fatal cases of Bell's disease and 
other cases resembling it occurring in their respective institutions, 
together with the results of autopsies with especial reference to the 
condition of the brain and the viscera. 

A resolution was adopted bearing witness again to the benevo- 
lent motives and untiring perseverance of Miss Dix ; it recom- 
mended the passage of the act by Congress and encouraged her to 
continue her efforts in behalf of the bill referred to at the last 
meetins:. 




/ < 



DR. JOHN S. BUTLER. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS |/21 






Dr. Kirkbride read a report containing his famous series '>ot^ 
" propositions " in reference to the erection and internal arrangK^^'^j STA"\ 
ment of hospitals for the insane, which will be found referred to "^^^^--rr: 
at length elsewhere. 

The report of Dr. Ray presented at Boston does not seem to 
have been discussed at this meeting. 

The seventh meeting of the Association was held at the Irving 
House, in the City of New^ York, May i8, 1852. Twenty-six per- 
sons were present. 

A resolution was passed requesting the standing committee on 
the construction of hospitals to present also a series of resolutions 
embodying similar propositions relating to the direction, organiza- 
tion and management of hospitals for the insane. 

A resolution was adopted appointing Dr. Bell to report upon 
the proper disposition to be made of persons charged with crime 
and acquitted on the ground of insanity ; also upon the care of 
insane criminals in state prisons, both with reference to the best 
interests of the insane and the community at large. 

The eighth meeting of the Association was held in Baltimore, at 
the Eutaw House, on the loth of ^lay, 1853. About 20 persons 
were present. Much time at this meeting seems to have been 
spent in excursions, on one of which the almshouse was visited. 
The members promptly by resolution said that they felt keenly the 
condition of the insane in almshouses, because in the wards set 
apart for their care " there zuas seen a type of treatment to which 
this unfortunate class of fellow-beings had been subjected during 
the darkest period of history," which indicated that the Association 
still had the courage of its convictions. 

An important paper was presented by Dr. Kirkbride on the 
night care of the insane. The discussion which followed brought 
to light considerable difference of opinion. Many concurred in 
the paper and believed night care to be essential to detect and pre- 
vent fire, to effect a proper policing of institutions, and to correct 
untidy habits on the part of patients by giving them night atten- 
tion and nursing. It was evident, however, from the discussion 
that many New England institutions had no night watchmen and 
that some of the best superintendents did not regard night watch- 
ing as conducive to the comfort of their patients. It is probable 



22 INSTITUTIONAL CARE OF THE INSANE 

that each member preferred what he had become accustomed to 
and may not have had an open mind. 

An interesting discussion occurred as to whether typhomania, 
Bell's exhaustive mania and a form of disease described by Dr. 
Ray were identical diseases. The general trend of the discussion 
seemed to establish the accuracy of the original observations of Dr. 
Bell. 

The ninth meeting of the Association was held on May 9, 1854, 
at the Smithsonian Institution in the City of Washington, D. C. 
Twenty-two members were present. 

Beyond a paper by Dr. Edward Jarvis on the tendency of un- 
balanced minds to develop insanity, there was little in the way of 
elaborate articles at this meeting. 

In a discussion on treatment, Dr. Curwen deplored too frequent 
bleeding in cases of excitement. 

Dr. Waddell, of New Brunswick, spoke of the use of tartarized 
antimony as an excellent substitute for bleeding. It is interesting, 
however, to note that several members expressed their disapproba- 
tion of the use of this depressing agent. 

Dr. Ray recommended a sustaining treatment and suggested 
that sometimes his patients required a variety of distilled liquors. 

The general impression seemed to be that it was not advisable to 
use depressing agents in the treatment of acute insanity. 

In view of the modern somewhat extravagant exploitation of the 
continuous bath as a new therapeutic agent in the treatment of 
acute insanity, it seems proper to mention the fact that Dr. Brown 
recommended its use for periods of from six to eighteen hours. 
Several superintendents, however, were opposed to such use of 
the bath and believed that prolonged immersion did more harm 
than good. 

The tenth meeting of the Association was held in the City of 
Boston, at the Tremont House, on May 22, 1855. Twenty-six 
members were present. Dr. I'ell retired as president and Dr. Isaac 
Ray was elected in his place. 

Almost the first note of discord in the history of the Association 
developed over an article published in an issue of the American 
Journal of the Medical Sciences, ascribed to Dr. John M. Gait, of 
Virginia, in which he spoke of one of the New England institutions 
being under the control of " one of the most pertinacious tinkers 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 27, 

of gas pipes." There were also other caustic references to the 
institutions of New England which were unfavorably compared to 
those in the South. In the course of the discussion Dr. Workman, 
of Toronto, thought that too much attention had been given to the 
strictures, presumably, of Dr. Gait. He believed that the asylums 
for the insane were all still short of perfection, a fact which was 
abundantly proven by the published reports of the superintendents, 
in which mention was made of many defects in construction and 
equipment: if these reports were to be believed, in his opinion. Dr. 
Gait should not be censured. 

xA.n elaborate and highly interesting paper from a literary point 
of view was presented by Dr. Isaac Ray on the " Insanity of George 
III." 

A paper was read by Dr. Buttolph on the influence of the recum- 
bent position in increasing the vital energies in disease, which 
seems to have been the first paper upon this subject presented to 
the Association. The discussion which followed brought out the 
first reference to what was afterwards known as the crib bedstead. 
Dr. Gray described the use of the crib bedstead in the hospital, at 
Utica, and spoke well of it. Drs. Nichols and Buttolph defended 
its use; upon the whole, although several opposed its use, the 
opinion of those present seemed to be in its favor. 

The eleventh meeting of the Association was held at the Spencer 
House, Cincinnati, Ohio, May 19, 1856. About 28 members were 
present. 

A paper was presented by Dr. Worthington on a case of prom- 
inence of the eye-balls, accompanied by disease of the heart and 
thyroid glands, which seems to have been one of the earliest papers 
presented on Basedow's disease in this country. 

Dr. Edward Jarvis, of Dorchester, Mass., presented a paper on 
the care of the criminal insane in which he made a plea for special 
provision for insane criminals. He believed it to be unwise and 
improper to leave them in prisons without hope or prospect of 
recovering their health. They had a claim to treatment and cure 
and should be sent to hospitals. No man, while insane, could be 
punished with propriety by confinement in a prison. It was unwise 
to send insane criminals to hospitals for the insane because their 
presence disturbed the administration of hospitals and harmed the 
innocent insane. Criminal patients are as a class cunning and not 



24 INSTITUTIONAL CARE OF THE INSANE 

trustworthy, and being accustomed to imprisonment they under- 
stand how to make their escape, and thus break up disciphne and 
good order, and render it necessary to exercise a strict disciphne 
over all other patients, the greater part of whom otherwise might 
enjoy a large degree of liberty. The only proper method for the 
care of insane convicts was to provide special institutions for them, 
located near to prisons but unlike them, and possessing all the 
features of a hospital for the acute insane. Insane convicts should 
be made secure so that they may not escape, and should be under 
the care of good nurses; occupation should be provided for them. 
As he believed that no state alone could provide a criminal hospital, 
he recommended that New England and New York should com- 
bine for the purpose and that possibly New Jersey and Eastern 
Pennsylvania should be included in the same combination. He 
recommended that Delaware, Maryland, Virginia, the Carolinas, 
Georgia and Florida should establish another criminal hospital. 
The Western states should form a district for the third, and the 
Southwestern states for the fourth. It is evident in the light of 
our present knowledge that the method proposed was altogether 
inadequate, as in fact the criminal insane at present require to be 
cared for in one or more institutions in almost every state. Hos- 
pitals in connection with prisons also have not been satisfactory 
and have generally been abandoned. 

The meeting was not well rei)orted, and it is impossible to follow 
the discussion which is stated in the minutes to have been of un- 
usual interest. 

The twelfth meeting of the Association was held at the Metro- 
politan Hotel, New York, May 19, 1857. Thirty-five persons were 
present. The principal paper was presented by Dr. John E. Tyler, 
then of the New Hampshire Asylum, in reference to the care of 
the violent insane, in which he recommended that violent patients 
be placed in strong rooms built substantially, but which should be 
light, cheerful, well ventilated and thoroughly comfortable. In the 
discussion which followed considerable difference of opinion de- 
veloped. 

Many preferred that violent patients should be cared for in a 
lodge or detached building, where patients, who were noisy or 
violent, could be placed at such distance from the other wards as 
not to interfere with the comfort of quiet patients. The general 



- i 




DR. XEHEMIAII CUTTER. 



ASSOCIATION OF MEDICAL SUPERIXTENDEXTS 25 

feeling seemed to be against the use of strong rooms, and one 
or two superintendents expressed a preference for mechanical 

restraint. 

Dr. Ranney presented a paper on the medical treatment of insan- 
ity, in which he recommended the use of tartarized antimony and 
arterial sedatives during the height of excitement, to be followed 
by morphia and later by tonics. There was nothing especially new 
in the paper which, nevertheless, gave rise to an extended dis- 
cussion. The general sentiment seemed to be opposed to the use 
of tartarized antimony or venesection. Many spoke favorably of 
the use of opium, hyoscyamus and other anodyne remedies. 

The thirteenth meeting of the Association was held at Russel 
Hotel, Quebec, June 8, 1858. Twenty-four persons were present. 
Dr. Curwen was appointed secretary. At this meeting the first 
mention is found of a new form of disease known as general 
paresis, brought to the attention of the Association by interesting 
pathological memoranda presented by Dr. Workman. It is of 
interest to observe the relative frequency of the disease as reported 
from different sections of the country. Dr. Choate stated that he 
received from two to five cases of the disease annually but had 
never seen any case in a woman. Dr. Workman had seen 15 cases, 
only one of which had been intemperate. Dr. Athon, of Indian- 
apolis, had seen five cases within five years, three being men and 
two being women. Dr. Green had not seen a case in eight years. 
Dr. Chipley stated that the disease was rare in the West ; he had 
seen but three cases in three years. Dr. Hills had never seen more 
than three or four cases in all his experience. Dr. Ray in summing 
up expressed the opinion that the relation of general paresis to 
other forms of insanity required to be more thoroughly investi- 
gated. He believed it to be impossible to draw a dividing line 
between general paresis and other forms of disease. It seems prob- 
able to the editor that this statement is due to the fact that the 
diagnosis was confused by the observation of such patients at dif- 
ferent stages of the disease. 

At this meeting an excellent paper was read by Dr. Isaac Ray 
on mental hygiene which will prove profitable reading to all per- 
sons w^ho have an impression that mental hygiene is a subject but 
recently brought to the attention of medical men. 



26 INSTITUTIONAL CARE OF THE INSANE 

The fourteenth meeting of the Association was held at the 
Phoenix Hotel, Lexington, Ky., May 17, 1859. Seventeen persons 
were present. 

Dr. Ray resigned as president and Dr. Andrew McFarland was 
elected in his place. 

A paper was read by Dr. Mcllhenny on various means of 
restraint. In the discussion which followed all deprecated the use 
of restraining apparatus, and mentioned modifications which they 
had made in its application, but no person advocated absolute non- 
restraint. 

A paper was read by Dr. Chipley on what he called sitomania or 
refusal of food. This paper elicited descriptions of various 
methods of administering food to patients who declined to eat 
voluntarily. 

The fifteenth meeting of the Association was held at the Con- 
tinental Hotel, Philadelphia, May 28, i860. Thirty-four persons 
were present. 

The most important paper was presented by Dr. Jarvis, of 
Massachusetts, on the proper function of private institutions or 
homes for the insane. This paper, like all by Dr. Jarvis, suggested 
a variety of new topics, and was the first one to be read before the 
Association which had reference to special accommodations for 
dififerent classes of the insane. In it he spoke of the provision 
which had been made in England in corporate hospitals, in private 
institutions, and in county asylums established under the poor law, 
and contrasted it with what existed in this country, where all classes 
of patients were sent to public asylums. He believed that the great 
majority of cases are better provided for in public than in private 
institutions, and that where patients required special restraint or 
seclusion, or had suicidal or homicidal impulses, it was better that 
they should be in public than in private institutions. He considered, 
however, that the public hospital was more inelastic than the pri- 
vate home, because a larger number of patients required a greater 
degree of discipline, and a sacrifice in some instances of the inter- 
ests of the few to the necessities of the many. He thought that a 
class of patients remained who did not require the close restraint 
and guardianship of public institutions, and who might be cared 
for with great comfort to themselves in a private home under the 
care of a physician. In addition to this he believed that there were 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 2/ 

many quiet patients who did not c:et on well at home and must live 
away from their friends, who could reside in private families away 
from home not under the care of physicians. 

The paper was not approved by the members of the Association, 
the majority of whom believed apparently that the public institu- 
tion was better than the private home. In the remarks made by 
some of the members a degree of prejudice was manifested towards 
private institutions as compared with a public hospital, or cor- 
porate institutions like the IMcLean Hospital, the Hartford Retreat, 
Bloomingdale Asylum and the Pennsylvania Hospital. It is inter- 
esting, however, to observe the candid and fair mental attitude of 
Dr. Jarvis, who in many respects seems to have been in advance of 
his time. 

Dr. Harlow read a paper on inebriety as a disease, which was 
followed by a discussion eliciting many valuable clinical facts in 
reference to alcoholic insanity. This seems to have been the first 
reference in the Association to inebriety as a form of mental dis- 
ease. 

The meeting of the Association for 1861, which was to have been 
held, was postponed for one year on account of the Civil War, or 
as the Association stated in its resolutions, " on account of the 
excited state of the public mind caused by the violent efforts to 
overthrow the established government." 

The sixteenth meeting of the Association was held at the City 
Hotel, at Providence, R. I., on June 10, 1862. Twenty persons 
were present, none of them from south of Mason and Dixon's line. 

The secretary read a letter from Dr. W. S. Chipley, of the asylum 
at Lexington, Ky., stating that he was absent from the Association 
because his attendance was required by the wounded of the Army 
of the Southwest. Dr. Andrew McFarland also wrote that the 
late battles in the Southwest and the large number of wounded 
from his own state made it impossible for him to leave home. Dr. 
McFarland resigned as president and Dr. T. S. Kirkbride was 
elected in his place. 

The most elaborate paper of the meeting was by Dr. Joseph 
Workman, of Canada, on latent phthisis in the insane which 
developed an interesting discussion. In the light of our present 
knowledge of tuberculosis, it is evident that Dr. Workman had con- 
fused a condition which may be developed among the insane by 
5 



28 INSTITUTIONAL CARE OF THE INSANE 

unhygienic conditions and a possible infection from other tuber- 
culous patients with what he conceived to be the inevitable course 
of insanity. Feeble patients confined in overcrowded hospitals 
upon an insufficient diet, we now know, are peculiarly liable to con- 
tract tuberculosis. The writer of the paper, however, believed that 
tuberculosis was a logical and natural termination of insanity. 

Dr. Jarvis read a paper mainly derived from his observations 
of the hospitals and asylums in England in regard to the employ- 
ment of inmates of institutions in trades. The paper was mainly 
of interest because it brought out the fact that institutions in this 
country employed patients in desultory labor in a haphazard way. 
It seems strange to us at the present time that superintendents of 
institutions, in the light of the knowledge which they had as to the 
practice in England, accomplished comparatively little in the way 
of systematic employment of their patients. It is probably to be 
explained by the fact that the majority of them were advanced in 
years, and were no longer equal to the eiTort of initiating new 
methods of employment, or of systematic efiforts to utilize the labor 
of patients. 

The seventeenth meeting of the Association was held at the 
Metropolitan Hotel, New York, on May 19, 1863. Twenty-five 
persons were present. The only member of the Association from 
the Southern states was Dr. W. S. Chipley, of Lexington, Ky. 

This meeting witnessed the first discussion of a question which 
later occupied much attention in the meetings of the Association, 
viz. : the existence of so-called moral insanity. The discussion fol- 
lowed a paper from Dr. McFarland on minor mental maladies. It 
is interesting to see that those who favored the doctrine of moral 
insanity and were most emphatic in upholding it were Dr. Nichols, 
of Washington, Dr. Tyler, of Boston, and Dr. Ray, of Providence, 
all of whom took the ground that the mind, which we now regard 
as a unit, was really divided into three distinct divisions : the reason, 
the will and the emotions. Each contended that any one of the 
three metaphysical divisions of mental action might be a subject of 
disease without afifecting the other. Those who opposed this view 
were Drs. Chipley, Walker, Gray, Ranney, and Workman, who 
argued for the physical basis of all mental disease, and believed 
that whether the mental derangement showed itself in the form of 
a weakened will or a perverted emotional state, there was also intel- 




DR. PLIXV EARLE. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 29 

lectual disturbance, either in the form of changed mental activity, 
delusions or other marked mental derangement. 

The eighteenth meeting of the Association was held at Willard's 
Hotel, Washington, D. C, May lo, 1864. There were present 18 
persons, of whom two, Dr. W. P. Jones, of Nashville, Tenn., and 
Dr. John Fonerden, of Baltimore, Md., were from the Southern 
states. 

One of their first acts was to pass a resolution to appoint a com- 
mittee to wait upon the Surgeon-General of the United States to 
tender the services of the members to assist in the care of the sick 
and wounded at Fredericksburg. 

One of the most valuable papers presented was by Dr. Gray, of 
Utica, on a case of pellagra, of which he gave the history. This is 
the first mention in the proceedings of the Association of this dis- 
ease. In the discussion which followed it is of interest to learn that 
Dr. Tyler had seen a case several years before, which at the time 
he had been unable to classify, but which he now recognized as 
pellagra. Dr. Earle also called to mind the fact that while in Italy 
25 years before he had seen several cases of pellagra in his visit to 
a hospital for the insane in Milan, and stated that he had made a 
brief record of these cases in the American Journal of Medical 
Sciences in 1844 under the heading, " Visits to Thirteen Asylums." 

Much of the session was taken up with a long discussion upon 
the best methods of heating and ventilating institutions. 

Dr. Ray's project of a law on the legal relations of the insane 
was presented, and after much discussion it was ordered that the 
paper proposed by Dr. Ray be printed and circulated among the 
members of the Association for criticisms which later should be 
forwarded to Dr. Ray, who had been constituted a committee to 
make a report upon it at the next meeting of the Association. 

Miss Dix was introduced at one session and gave an interesting 
account of her labors among the sick and wounded in the recent 
battles. 

The nineteenth meeting of the Association was held at the 
Monongahela House, Pittsburgh, May 13, 1865. Nineteen mem- 
bers were present. 

Dr. Chipley read an interesting paper on feigned insanity : its 
motives and special tests for detecting it, which elicited consider- 
able discussion from the members, and oral reports of many 
clinical cases. 



30 INSTITUTIONAL CARE OF THE INSANE 

Dr. Kirkbride read a report on heating and ventilating institu- 
tions which reiterated the propositions originally adopted by the 
Association many years before. The discussion developed the fact 
that the majority of the institutions were heated by steam and that 
nearly all were provided with fans for forced ventilation. 

Considerable discussion was aroused by a letter from Dr. D. 
Tilden Brown, questioning the propriety of the appearance of 
several offensive phrases in the English Journal of Mental 
Science, in a notice of Dr. Ray's sketch of the late Dr. Luther V. 
Bell, wherein the editor of the Journal says: "That Dr. Bell, 
although feeble in health and with anxious domestic cares, was 
moved by the demon of war to go forth and aid President Lincoln's 
hopeless and insane attempt to force on the Southern Confederates 
the mob-rule of the North by aid of foreign hirelings and ex- 
attorneys-general." 

Dr. Brown further proposed the adoption of a resolution alleging 
that this statement was regarded by the Association as an unjust 
aspersion on the character of its former honorable president, and 
unworthy of the Association of which the Journal of Mental 
Science was the official organ. The resolutions were adopted by a 
unanimous vote. 

The twentieth meeting of the Association was held in Washing- 
ton, on April 24, 1866. Twenty-seven members were present. 

The proceedings were printed with unusual fullness because for 
the first time all discussions were reported by a stenographer. 

The question of moral insanity was brought up again by a paper 
from Dr. Chipley reviewing the legal decision of a court in Ken- 
tucky which announced the recognition of moral insanity as one 
of the principles of law. This precipitated a long and, as usual, an 
inconclusive discussion, during which the different members of the 
Association occupied their respective sides of the controversy with 
the avowed intention of disposing of the subject for all future time. 
Nothing new came of the discussion. 

A paper presented bv Dr. George Cook upon the condition and 
care of the insane poor in the State of New York was read and gave 
rise to a prolonged debate. 

Two series of resolutions were presented to the Association, the 
first reading practically as follows : 

That each state should make provision for all indigent insane persons 
within its limits. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 3I 

That each hospital should be located as near as possible to the center of a 
given district so that patients may be conveyed to it with as little expense 
and risk to life as possible. 

That it is unwise and inhumane and not economical to attempt to make 
the labor of the insane pecuniarily remunerative or primarily contributive 
to their support. That no class of insane except those suffering from 
chronic and advanced dementia should be cared for outside of a properly 
constructed, equipped and organized hospital. 

And the second series : 

That the state should make ample and suitable provision for all its insane. 

That no insane person should be treated in any county poorhou?e or 
almshouse in which paupers are maintained and supported. 

That a proper classification is an indispensable element for proper treat- 
ment and can only be secured in establishments especially constructed for 
treatment. 

That curable and incurable persons should not be cared for in separate 
establishments. 

These propositions were discussed at length by Drs. Gray, Ban- 
croft, Nichols and other prominent men who were generally 
opposed to the separation of the curable and incurable insane. 

Dr. Cook presented, in place of the resolutions committing the 
Association to a record of its preference for hospital provision for 
all the insane whether chronic or acute cases, a substitute which 
provided that the question should be presented in any given state 
whether or not the chronic insane shall continue to be placed in 
county poorhouses, or whether provision shall be made for them 
in institutions built at less cost in connection with existing hospitals 
for the insane. This resolution received but a single vote, that of 
Dr. Cook. 

Dr. Chipley presented a substitute containing the following 
propositions which were unanimously adopted : 

That each state should make ample and suitable provision for all of its 
insane. 

That insane persons considered curable and those considered incurable 
should not be provided for in separate institutions. 

Dr. Nichols subsequently presented a series of five resolutions 
which provided : 

1. That the large states should be divided into geographical districts so 
that hospitals could be placed nearly in the center of them and thus be 
accessible to all persons living within their boundaries and available for 
treatment. 

2. That all state, county and city hospitals shall receive persons in their 
vicinity, whatever may be the form or nature of their mental disorder. 



32 INSTITUTIONAL CARE OF THE INSANE 

3. Tliat all hospitals for the insane be constructed, organized and managed 
according to the propositions of 1851 and 1852. 

4. That the facilities for classification or ward separation of each insti- 
tution shall be equal to the requirements of the several classes of insane 
received by the institution. 

5. And finally, that the enlargement of a state, county or city institution 
may be properly carried to 600 patients if such be required for the care of 
the insane. 

The first four propositions were unanimously adopted, and the 
fifth was carried by a vote of eight to six and the resokitions as a 
whole were adopted by a vote of nine to five. 

The twenty-first meeting of the Association was held in Phila- 
delphia on May 21, 1867. Thirty-two persons were present. 

The most important communication presented was a paper on 
" Aphasia," by Dr. H. B. Wilbur of the Hospital for the Feeble- 
minded at Syracuse, N. Y. It is not known whether this paper was 
discussed or not. 

Beyond the fact that there was much animated and earnest dis- 
cussion on the care of the chronic insane, few details of the meeting 
are accessible in the volume of the American Journal of Insanity. 

The Association decided at this meeting to publish the proceed- 
ings hereafter separately in pamphlet form, in view of some dis- 
satisfaction with the comments of the editors of the American 
Journal of Insanity upon the care of the chronic insane. 

The twenty-second meeting was held at the American House in 
Boston, June 2, 1868. Thirty-two members were present. 

The principal business of the Association was the discussion and 
adoption of a project of law for determining the legal relations of 
the insane. 

The Association also adopted a memorial to the Congress of 
the United States in favor of relieving froin political disabilities the 
superintendents of the hospitals for the insane in the states "lately 
in rebellion." 

The Association visited all the institutions for the insane in 
Boston, and several general hospitals and other institutions, and 
received many courtesies from the officers and trustees, and also 
from the officers of Harvard College. 

At the meeting of the Association in New York in May, 1863, a 
committee had been appointed to examine the whole subject of the 
legal relations of the insane, and to report the legislation required 




DR. JOHN MINSON GALT. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 33 

to regulate them. The committee consisted of one from each state, 
viz. : Drs. Harlow, of Maine ; Bancroft, of New Hampshire ; Rock- 
well, of Vermont ; Jarvis, of Massachusetts ; Ray, of Rhode Island ; 
Butler, of Connecticut; Gray, of New York; Buttolph, of New 
Jersey; Curwen, of Pennsylvania; Fonerden, of Maryland; 
Nichols, of the District of Columbia; Gundr}^, of Ohio; Wood- 
bum, of Indiana; McFarland, of Illinois; Van Deusen, of Michi- 
gan; Clement, of Wisconsin; Patterson, of Iowa; Smith, of Mis- 
souri ; Chipley, of Kentucky ; Jones, of Tennessee ; and Workman, 
of Canada and the British Provinces. At the next meeting of the 
Association, in Washington, May, 1864, the committee presented a 
report through its chairman. Dr. Ray, which was accompanied by 
the project of a general law. After considerable discussion, the 
further consideration of the subject was postponed to the next 
meeting, but owing to the absence of the chairman, it was not 
resumed until this meeting in Boston. After thorough discussion 
and considerable modification the project of law was adopted 
unanimously.^ 

The twenty-third meeting was held at Staunton, Va., June 15, 
1869. Twenty-five members were present. 

The following resolution in regard to religious services in insti- 
tutions for the insane was adopted : 

Resolved, That this Association hereby expresses its earnest conviction 
that religious services of some kind in our institutions for the insane are 
generally highly salutary to their inmates, and should be regularly held, and 
that the Association hereby reaffirms the ninth proposition of the series 
adopted in relation to the organization and management of hospitals for the 
insane in 1856. 

Dr. Nichols presented to the Association a system of statistics 
adopted at the International Congress of Alienists, held in Paris, 
1867, and the papers were referred to a committee consisting of 
Drs. Jarvis, Nichols and Stribling. Nothing, however, came from 
this committee. 

The twenty-fourth meeting was held at Hartford, Conn., on June 
15, 1870. Thirty-nine members were present. 

Dr. Kirkbride, who had been president for many years, declined 
to serve longer and Dr. John S. Butler, of Hartford, was elected 
president. 

*See Appendix, page 49. 



34 INSTITUTIONAL CARE OF THE INSANE 

At this meeting the custom of calHng upon the members of the 
Association from different parts of the United States to give an 
oral statement of the condition of the institutions in their respec- 
tive states was inaugurated. This routine practice continued for 
a number of years and afforded to members an excellent oppor- 
tunity of learning what had been accomplished throughout the 
country in the matter of increased provision for the insane. 

A paper was read by Dr. Isaac Ray on the prognosis of insanity, 
which was discussed at great length without reaching any special 
conclusion. 

Dr. Barstow presented a paper on the systematic instruction of 
patients, which elicited discussion. It may be remembered that 
Dr. Brigham, of the State Asylum, at Utica, inaugurated such 
systematic instruction many years before. 

Dr. Ranney said that in the Iowa State Hospital, systematic 
school exercises had been introduced during the past two years. 
There had been also systematic teaching at the McLean Asylum 
and at the Eastern Asylum at Williamsburg, Va. Several mem- 
bers present, however, opposed the introduction of school instruc- 
tion unless the work could be done in such a way as to relieve the 
ordinary monotony of a school. Many preferred light gymnastics, 
military drills, or light employment calculated to occupy the atten- 
tion of the individual without tiring him. 

A discussion arose later upon the use of hypnotics, especially of 
chloral hydrate, which was beginning to be used extensively in 
hospitals to produce sleep. 

The twenty-fifth meeting of the Association was held at Toronto, 
Canada, June 6, 1871, under the presidency of Dr. John S. Butler, 
of Hartford. Thirty-seven members of the Association were pres- 
ent and six additional persons by invitation. 

For some years previous there had been much discussion as to 
the advisability of uniting the Association with the American Medi- 
cal Association. Dr. Curwen, who had been appointed a delegate 
to attend the San Francisco meeting of the latter association, 
reported that after due consideration it had been agreed on the 
part of both Associations that such a union was not wise. The 
report was accordingly accepted. 

A long discussion then occurred upon the fruitful theme of 
many previous meetings, namely, the proper size to which existing 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 35 

institutions might be enlarged. A resolution was finally adopted 
permitting an increase to 600 patients as a maximum. This seems 
to have been the last time an attempt was made in the Association 
to prescribe what the size of any institution should be. The resolu- 
tion was adopted by a majority vote. 

Dr. H. B. Wilbur, of Syracuse, presented a paper on moral 
insanity, which, as usual, gave rise to an animated discussion with 
no harmonious conclusions. 

Dr. Joseph Workman, of Toronto, presented an interesting paper 
from a historical standpoint on demonomania and witchcraft, 
which, as an interesting example of historical research, elicited an 
animated discussion. 

The commission on statistical tables presented forms of tables, 
21 in number, covering the statistics which were deemed desirable 
in connection with the Association. These tables were used for 
some years but were never generally adopted and passed out of 
general use at the time when commissions in lunacy in the different 
states prescribed special tables for their statistics. They were 
largely adapted from English tables, and as they did not grow out 
of the needs of institutions in this country, they had little value. 

Resolutions were adopted commending didactic and clinical 
instruction upon insanity in connection with the medical schools of 
the country, which was the first of^cial recognition of the necessity 
of giving better instruction in psychiatry to medical men. 

Probably the most interesting paper of the meeting was pre- 
sented by Dr. Jarvis, of Massachusetts, on the cottage system for 
the care of the insane. The discussion developed much difiference 
of opinion as to the advisability of erecting cottages, but it was 
evident from the opinions expressed that the movement had gained 
the approval of a large number of the members of the Association. 

The twenty-sixth meeting of the Association was held at Madi- 
son, Wis., May 28, 1872. Forty-one members were present. Dr. 
J. S. Butler was president. 

A paper was presented by Dr. Curwen on the diagnosis and 
treatment of insanity, which once more brought prominently before 
the Association the doctrine of moral insanity. In the discussion 
of the paper a brave member, who had apparently not attended 
previous meetings, ventured to inquire whether or not the Associa- 
tion recognized the existence of moral insanity, which again 
brought up the subject for renewed and inefifectual discussion. 

6 



36 IXSTITUTIONAL CARE OF THE INSANE 

Dr. Gray read a paper on the causes of insanity, in which he 
formulated his views as to the physical basis of all mental disease. 
He also gave some account of his pathological studies. 

A large portion of a long session was spent in oral reports 
from members of the Association as to what was being done for 
the insane in their own states. The reports given by the majority 
were disheartening, because they showed that nearly every state 
was far behind its needs in ade([uate provision for the insane. 

An interesting paper was read by Dr. Isaac Ray on the criminal 
law in regard to insanity, which was followed by a long discussion. 

A series of resolutions were presented and unanimously adopted, 
protesting against admitting a greater number of patients to any 
institution than its buildings could properly accommodate. 

Dr. Ranney, of Iowa, gave an account of the recent legislation 
in that state to secure a closer inspection of institutions for the 
insane. A commission, comprising a lawyer, a physician and a 
lady, was required to visit hospitals monthly or oftener, and had 
power to discharge any person employed in the institution who in 
its opinion merited discharge. The commission was also required 
to see that all letters written by patients were sent to their friends. 
He reported that as a medical ot^cer of the institution at Mt. 
Pleasant he had complied with the new law conscientiously, but 
that the legislation had caused great dif^culties in maintaining 
discipline in his institution. 

The twenty-seventh meeting of the Association was held at the 
Eutaw House, Baltimore, May 2'], 1873. Fifty-two members were 
present. The first day of the session was largely occupied in 
receiving reports from the different states. 

Dr. John S. Butler presented his resignation as president and 
Dr. Charles H. Nichols, of Washington, D. C, was elected to 
fill his place. 

Dr. C^ray read a paper on the pathology of insanity, which elicited 
some discussion, but it was evident that neither Dr. Gray nor the 
members who discussed the paper had much definite knowledge of 
the subject. The paper is to be commended as one of the early 
attempts at purely scientific work. 

The twenty-eighth meeting of the Association was held at Nash- 
ville, Tenn., May 19, 1874. The vice-president. Dr. C. A. Walker, 
occupied the chair. Thirty-five members were present. 




DR. THOMAS STORY KIRKBRIDE. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS "^J 

The first day's session was occupied in the presentation of 
reports from the diflferent institutions of the country. These 
reports indicated that a general effort was making or had been 
made in nearly every state to erect new institutions or to increase 
the capacity of institutions already existing in order to accommo- 
date the rapidly increasing number of insane patients. The general 
outlook seemed to be encouraging. 

A paper was presented by Dr. Ranney, of Iowa, in reference 
to the working of a law in that state entitled : " An Act to Protect 
the Insane." It was in effect a defense of the use of mechanical 
restraint. The covered bed was, in the opinion of the writer, as 
comfortable as an ordinary bed and most useful in the case of 
suicidal patients. He believed that the covered bed afforded a full 
equivalent for watching or other supervision and was not liable to 
interfere with sleep. 

In the discussion which followed there was a general agreement 
that his views were correct, and they were generally endorsed. 

The acting president of the Association in concluding the dis- 
cussion deprecated laudations of restraint, but expressed the belief 
that the amount of restraint in this country had been reduced to 
a minimum. He made the statement also that in his experience in 
English institutions considerable complaint had been heard from 
the medical officers because they were prohibited from using 
mechanical restraint. 

During the session a lengthy and inconclusive discussion 
occurred upon the use of chloral hydrate and other hypnotics. It is 
evident from the remarks of the members that hypnotic remedies 
at that time were generally used in many institutions throughout 
the country. 

The meeting had many interesting social features, but no paper 
of moment was presented. 

The twenty-ninth meeting of the Association was held at 
Auburn, N. Y., May i8, 1875. Forty-nine members were present, 
and 13 other persons by invitation. Dr. Charles H. Nichols was 
president. 

The first day's session was largely occupied in receiving reports 
from the different states. 

Dr. Gray read a paper on the pathological changes in the brain 
detected by the microscope with illustrations of disease by means 



38 IXSTTTUTIONAL CARE OF THE INSANE 

of a stereopticon. This was the first pathological paper presented 
to the Association in this manner. 

Dr. J. C. Bucknill, of England, was a visiting delegate to the 
Association and participated in the discussions. 

The Association passed a series of resolutions that it is the duty 
of each one of the United States and each one of the provinces of 
the Dominion of Canada to establish proper institutions for the 
care of inebriates, to which patients can be committed and there 
detained against their wills until such time as they are able to exer- 
cise self-control in the matter of the use of alcoholics. The meet- 
ing seems to have been barren of any elaborate papers or practical 
action, although there were extensive and interesting discussions 
upon a variety of topics relating to the insane. 

The thirtieth meeting of the Association was held in Philadel- 
phia, June 13, 1876. Fifty-six members were present, and about 
20 other persons by invitation. 

Reports were received from the different states in more or less 
detail respecting actual provision for the insane. Members gave 
interesting reports from Maine, Rhode Island, New York, New 
Jersey, Pennsylvania, Virginia, West Virginia, North Carolina, 
South Carolina, Georgia, Mississippi, Texas, Tennessee, Louisiana, 
Ohio, Illinois, Indiana, Wisconsin, Iowa, Missouri, Minnesota, 
Massachusetts and the District of Columbia ; from New Bruns- 
wick and Ontario. These reports were limited to what had already 
been done and no time was devoted to the consideration of future 
plans. 

In each state there were complaints of overcrowded institutions 
and insufficient provision for the immediate needs of patients. 
Many new institutions were in process of erection and many older 
institutions were being enlarged to satisfy the need of further 
accommodation. 

Two papers were presented on a comparatively new subject. 
Dr. Denny, of Hartford, Conn., spoke of the newer methods of 
pathological investigation and Dr. Gray, of the Utica State Hos- 
pital, gave an account of the pathological studies which had been 
made at his institution. Many of the results of such investigations 
were vague, and in the light of our present knowledge somewhat 
misleading. The papers, however, indicated that the minds of the 
members were turned towards increased scientific work. 




DR. ISAAC RAY. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 39 

Dr. Ray presented a paper on the criminal responsibility of the 
insane which was discussed by many members. During the dis- 
cussion the New York law of 1874, to determine the presence of 
insanity in criminal cases, was highly commended. By the pro- 
visions of this law it was possible to secure the examination of per- 
sons indicted for crime, in w^hose behalf insanity had been pleaded 
as a bar to conviction, prior to a trial. The law gave the governor 
of the state the right to appoint three experts to investigate the 
condition of the patient and to report to him prior to his action. 
During the discussion the weakness of the hypothetical question 
which had given unusual preponderance to the evidence of so- 
called experts was dwelt upon by several speakers. 

A discussion also took place in regard to the law in Maine, under 
the provisions of which it was possible to commit a person accused 
of crime and who gave evidences of insanity to an institution for 
the insane for observation prior to trial. 

An interesting feature of the proceedings was a statement made 
by Dr. Ray and Dr. Kirkbride, both residents of Philadelphia, as to 
the lamentable conditions of insane persons in the Blockley Alms- 
house. 

Another paper worthy of consideration was presented by Dr. 
Baldwin, of Virginia, on furloughing patients. The sentiment of 
the Association seemed to be in favor of the experimental removal 
of incurable patients, and the suggestions of Dr. Baldwin were 
generally approved. 

The thirty-first meeting of the Association was held at St. Louis, 
at the Lindell Hotel, May 29, 1877. Dr. Nichols was president. 
Forty members of the Association were present, and six others, 
mainly trustees of institutions or secretaries of boards of charities, 
were present by invitation. 

The call of states for reports on the condition of the insane and 
the progress made occupied the first day. Reports were received by 
members from Ohio, Rhode Island, New York, New Jersey, Penn- 
sylvania, West Virginia, North Carolina, Mississippi, Texas, Ken- 
tucky, Indiana, Illinois, Wisconsin, Missouri, and from the Prov- 
ince of Ontario in Canada. 

In the report from Illinois, the first reference was made to Dr. 
Wines' plan of building a hospital in Illinois on what was termed 
the village plan, or in other words, after the model of a small town, 



40 INSTITUTIONAL CARE OF THE INSANE 

a plan which was afterwards carried into effect at Kankakee, 111., at 
Toledo, Ohio, and at Craig Colony in New York. 

A unique incident of the meeting was the celebration of the cere- 
mony of marriage between Dr. Andrew McFarland, a former 
president, and INIiss King, in the presence of the whole Association. 

The much worn subject of mechanical restraint of the insane 
was presented by Dr. Grissom. of North Carolina, in a paper 
entitled : " Mechanical Protection of the Insane." This was largely 
an indictment of the methods of non-restraint in England, and an 
attempt on the part of the author to show that non-restraint there 
had worked badly and had not benefited the insane. The paper was 
discussed at great length, and well-nigh every member seemed to 
favor the extreme statements made therein except Dr. Gundry, of 
Ohio, who pointed out the evils of restraint. It is evident that a 
preponderant sentiment in favor of mechanical restraint existed 
among the members, more especially among those who had lately 
come into the service. It is interesting to note that one of the 
advocates of restraint was Dr. R. M. Bucke, of Ontario, who later 
in his career became a strenuous advocate of non-restraint methods. 

Dr. Bucke read a paper on the " Functions of the Great Sym- 
pathetic,'' which was later developed into a book entitled " Man's 
Moral Nature." 

Dr. Gray read a paper on " Suicide." 

The thirty-second meeting of the Association was held at Wil- 
lard's Hotel, in the City of Washington, May 14, 1878. Dr. Nichols 
was president. Forty-nine members were present, and four others, 
members of boards of trustees, were present by invitation. 

An attempt was made to dispense with further reports on the 
conditions of the insane and provision existing for them in the dif- 
ferent states, but the effort proved unavailing, and much of the 
session was taken up in considering them. Reports were presented 
from Massachusetts, Connecticut, New York, New Jersey, Penn- 
sylvania, Maryland, \'irginia. West \'irginia, Mississippi, Ten- 
nessee, Kentucky, Texas, Louisiana, Missouri, Iowa, Wisconsin, 
Michigan, Ohio, North Carolina, Indiana, and the District of 
Columbia ; also from the Province of Ontario. 

It is evident that although these reports furnished nothing new 
to science they were of service because they gave a fuller knowl- 
edge of what was attempted throughout the United States. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 4I 

The report of a so-called case of kleptomania presented by Dr. 
Eastman, of Massachusetts, gave rise to an interesting discussion 
and furnished an occasion for a renewed difference of opinion upon 
the question of moral insanity. 

Dr. Wallace, of Texas, read a paper on the construction of hos- 
pitals in which he criticized the excessive cost of many hospitals 
and presented his own views as to the character of the buildings 
which he favored. 

Considerable feeling was displayed by some of the members who 
discussed the paper and who deemed it unfair to compare the cost 
of buildings in a state possessing, throughout the year, the mild 
climate of Texas, with that of institutions situated in the severer 
climate of Canada or New England. 

The thirty-third meeting of the Association was held in Provi- 
dence, R. I., at the Narragansett House, June lo, 1879, under the 
presidency of Dr. Nichols. Forty-seven members were present, 
and also several members of boards of trustees by invitation. 

Dr. Nichols, who had held the position of president for a num- 
ber of years, presented his resignation and Dr. C. A. Walker, of 
Boston, was elected to succeed him. 

The presentation of reports from the different states was omitted 
by unanimous consent and the sessions were largely occupied with 
the reading and discussion of papers. 

It is noteworthy that a paper was presented by Dr. Kirkbride 
which gave clinical notes of three cases under treatment in his 
own institution with autopsy findings. Dr. Kempster, of Wiscon- 
sin, also presented a series of pathological findings in connection 
with cases which had been under his care. 

Dr. Ray presented a paper on the curability of insanity, which 
elicited an earnest but inconclusive discussion. 

Dr. Shew, of Connecticut, read an interesting paper on a visit to 
Gheel : Dr. Draper, of \^ermont, on the responsibility of the insane 
while in hospitals. 

The thirty-fourth meeting of the Association was held at the 
Continental Hotel, at Philadelphia, May 25. 1880. Dr. C. A. 
Walker was president. Forty-nine members were present, and 
many other persons by invitation. 

An interesting paper was presented by Dr. C. F. MacDonald on 
feigned epilepsy, which gave rise to an interesting discussion and a 
report of a large number of similar cases. 
7 



42 INSTITUTIONAL CARE OF THE INSANE 

Dr. J. B. Chapin read a paper on experts and expert testimony, 
which was followed by a long discussion. All members favored a 
change in the law but none seemed to be able to suggest what should 
be done, there being no unanimity of opinion. 

The thirty-fifth meeting of the Association was held at Toronto, 
June 14, 188 1. Dr. J. H. Callender, vice-president, was in the chair 
in the absence of the president, Dr. Walker. Forty members were 
present, and a large number of other medical men and trustees of 
institutions were present by invitation. 

The death of Dr. Isaac Ray was announced and a full bibliog- 
raphy of his writings was presented in connection with a memorial 
notice prepared by Dr. Kirkbride. 

A paper on separate institutions for different classes of the 
insane was presented by Dr. Gundry, which was discussed at 
length. Considerable difference of opinion was developed among 
the members as to the advisability of providing separate institu- 
tions for different classes of the insane. The majority were of the 
opinion that it was better to gather all classes into one institution. 

The thirty-sixth meeting of the Association was held at the 
Grand Hotel, Cincinnati, May 30, 1882. Dr. Walker resigned the 
presidency and Dr. Callender was elected in his place. Forty-one 
members were present. 

It was decided to change the tenure of office of the president and 
vice-president of the Association so that in future they might be 
elected annually. 

It was also decided to reorganize the work of the Association 
into eight committees in order to give a fuller account of progress 
in the various branches of psychiatry. Committees were appointed 
as follows : 

1. Annual Necrology of the Association. 

2. Cerebro-Spinal Physiology. 

3. Cerebro-Spinal Pathology. 

4. Therapeutics of Insanity. 

5. Bibliography of Insanity. 

6. Relation of Eccentric Diseases to Insanity. 

7. Asylum Location, Construction and Sanitation. 

8. Criminal Responsibility of the Insane. 

It may be noticed here that while the object sought to be obtained 
was undoubtedly commendable, the division of responsibility im- 




DR. CHARLES HARRISON STEDMAN. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 43 

plied by committee work destroyed initiative on the part of indi- 
vidual members, and the scheme proved to be a failure and was 
soon given up. 

A paper was presented by Dr. R. M. Bucke, of Canada, entitled : 
" The Growth of the Intellect," which was an attempt to show how 
the human mind had developed at the different ages of the world. 

A paper was read by Dr. Richard Dewey on the differentiation 
and segregation of certain classes of the insane, in which he recom- 
mended separate provisions for the epileptic and criminal insane, 
also separate buildings for the chronic insane who no longer 
required the care and treatment usually given in the ordinary hos- 
pital buildings. The discussion developed a wide difference on the 
part of the members and there was no consensus of opinion. 

The thirty-seventh meeting of the Association was held at New- 
port, R. I., June 26, 1883, under the presidency of Dr. John P. 
Gray. Forty-three members were present, and a large number of 
invited guests. 

A report was read from the Committee on Cerebro- Spinal 
Pathology by the chairman. Dr. Daniel Clark, of Toronto. 

The Committee on the Therapeutics of Insanity reported 
through Dr. R. H. Gale principally upon the newer hypnotics. 

Dr. Joseph G. Rogers read a paper on the Therapeutics of 
Insanity. 

A report was also presented on the Bibliography of Insanity. 

The report of the Committee on The Criminal Responsibility of 
the Insane was presented by Dr. Everts and gave rise to a lengthy 
discussion. 

The thirty-eighth meeting of the Association was held at Phila- 
delphia, May 13, 1884. Dr. John P. Gray was president. Fifty 
members were present, and a large number of trustees, managers 
and others by invitation. 

The early sessions were occupied by tributes to Dr. Thomas S. 
Kirkbride, one of the oldest members of the Association, who had 
recently died. 

An interesting paper on the Therapeutics of Insanity and New 
Remedies was read by Dr. Andrews. 

One of the most important matters considered was presented by 
Dr. Foster Pratt, of Michigan, on the great increase of insanity 
in the United States, due to the unrestricted immigration of for- 



44 INSTITUTIONAL CARE OF THE INSANE 

eigners. In forcible resolutions which were unanimously adopted 
a plea was made that Congress should give immediate attention 
to the enactment of an immigration law to prevent the admission 
of insane and defective persons from Europe and Asia. This was 
one of the first steps taken by any public body to call the attention 
of the government to the great burden which the foreign insane 
had brought upon almost every state in the Union. 

In the discussion of a paper which had been presented on the 
subject of cheaper buildings for the insane, reference was made 
by Dr. Channing to the proposal recently made in Massachusetts 
to adopt what is termed mill construction, which is economical, not 
costing over $150 per capita, and for essential purposes is fireproof. 

During the sessions a resolution was submitted allowing assist- 
ant physicians in state and corporate institutions to become asso- 
ciate members of the Association after five years of continuous ser- 
vice in their hospitals. 

The thirty-ninth meeting of the Association was held at Sara- 
toga, June 16, 1885. Dr. Pliny Earle was president. Fifty-nine 
members were present, and many others by invitation. 

A report was read from Dr. Daniel Clark, as chairman of the 
Committee on Cerebro-Spinal Pathology. 

Dr. Andrews read a report from the Committee on Therapeutics 
of Insanity and New Remedies, in which he spoke of the thera- 
peutic use of tea, especially a fluid extract which had been made by 
Dr. Squibb. 

In a report presented on the resolution adopted to open the doors 
of membership in the Association to assistant physicians, some 
interesting facts were brought out. Replies had been received to 
personal letters from. 84 of the 94 public institutions in the United 
States. In these 84 institutions 208 assistant physicians were on 
duty ; 35 of them had been in service longer than one year ; 38 from 
one to two years ; 28 from two to three years ; 20 from three to 
four years ; 15 from four to five years ; 14 from five to six years ; 16 
from six to seven years ; 13 from seven to eight years ; seven from 
eight to nine years ; four from nine to ten years ; five from 10 to 11 
years; three from ii to 12 years; one from 14 to 15 years; three 
from 15 to 16 years ; one from 16 to 17 years ; one from 19 to 20 
years ; two from 20 to 21 years ; and one for 28 years. To sum up, 
73 assistants had served more than five years. As a result of this 




])K. FRANCIS T. STRIBLING. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 45 

report a resolution was adopted that five years' continuous service 
as an assistant medical officer should entitle him to membership in 
the Association as long as he shall continue a medical officer. 

An effort was made to change the name of the Association to 
the following: " The Association of Medical Superintendents and 
Physicians of American Institutions for the Insane," but the reso- 
lution was lost. 

A resolution was adopted that all assistant physicians connected 
with regularly constituted institutions for the insane be made ex- 
officio members of the Association. 

The fortieth meeting of the Association was held at Lexington, 
Ky., May 18, 1886. Dr. Orpheus Everts, of Ohio, was president, 
and 39 members were present. 

The number of formal papers presented was comparatively small 
and the proceedings were largely employed in discussions of cer- 
tain vital questions. 

Dr. W. D. Granger, of the Buffalo State Hospital, read an 
important paper on training schools for nurses in hospitals for the 
insane, which gave an account of the first training school in a state 
hospital, that at Buffalo, New York. In the discussion which 
followed interesting facts were elicited in reference to the first 
training school for nurses, which had been established at the 
McLean Hospital in Massachusetts, a department of the Massa- 
chusetts General Hospital. 

There was also an animated discussion on open doors in institu- 
tions for the insane, which brought out the interesting fact that 
many institutions had one or more wards with open doors for the 
better care of quiet patients. 

Dr. Foster Pratt presented interesting statistics respecting the 
increase of insanity by reason of pauper immigration from Euro- 
pean and Asiatic countries. 

The forty-first meeting of the Association was held at Detroit, 
June 14, 1887. Dr. H. A. Buttolph, of New Jersey, was president. 
Fifty-four members were present, and a number of physicians, 
trustees and others by invitation. 

The meeting was mainly memorable because of the increased 
number of scientific papers presented and the discussions which 
followed. 



46 INSTITUTIONAL CARE OF THE INSANE 

Dr. C. K. Clarke, of Canada, gave a paper on goitre and insanity 
which seemed to indicate that in certain sections of Ontario goiter 
prevailed among the residents to a much greater extent than the 
general average throughout Canada. 

Dr. W. L. Worcester read a paper with illustrative cases on 
localization of cerebral functions, which was one of the first on this 
subject to be presented to the Association. 

Dr. Cowles, of the McLean Hospital, read a paper on nursing 
reform for the insane, which gave full details of the methods 
employed in the instruction of nurses and the results obtained in 
the way of note-taking and history writing. 

The forty-second meeting of the Association was held at Fort- 
ress Monroe, May 15, 1888. Dr. John B. Chapin, of Pennsylvania, 
presided. Fifty-four members were present, and ten persons by 
invitation. 

A paper was read by Dr. Talcott on " Traumatic Insanity and 
Traumatic Recoveries," which elicited an interesting discussion. 

Dr. Steeves, of St. John, N. B., presented a paper on the " Rela- 
tions of Tuberculosis to Insanity," which brought out the fact that 
no special relation existed between tuberculosis and insanity. The 
number of patients in institutions dying from tuberculosis was 
found to be about the same as the proportion of tuberculous 
patients in general communities. The author believed that there 
was no necessary connection between tuberculosis and the develop- 
ment of insanity. If tuberculosis existed in the case of a patient 
in an institution there was reason to think that the circumstances 
of the institution were such as to favor an infection from some 
other patient or to lower his vitality so that tuberculosis might 
develop. 

Dr. Richardson, of Ohio, presented a jxiper on the practical 
working of the associate dining-rooms, which was one of the first 
accounts given of this manner of providing dining-room accom- 
modations for patients in the United States. 

A large part of the sessions of two days was taken up with a 
discussion of a report upon the modification of the "propositions," 
a fuller account of which may be found in a later chapter on the 
" propositions." 

The forty-third meeting of the Association was held at New- 
port, June 18, 1889. Dr. W. W. Godding, of Washington, was 




DR. SAMUEL WHITE. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 47 

president. Forty-seven members were present, and lo persons by 
invitation. 

A paper was presented by Dr. Preston, of Virginia, on the 
" Moral and Curative Effects of Associate Dining Rooms." This 
paper brought out the fact that associate dining-rooms were 
already in use at St. John, N. B.. at Norristown, Pa., at Harris- 
burg, Pa., and in Ohio. 

Dr. Stedman presented a paper on the family system of provision 
for the insane. In the discussion which followed considerable dif- 
ference of opinion was developed as to the utility of family care. 

Dr. A. R. Moulton, the secretary of the Massachusetts Board of 
Insanity, presented interesting statistics which showed the great 
advantage of such care to selected patients. He stated that 113 
patients were boarded out in Massachusetts and that their condition 
was more comfortable than had been the case in an institution. 

Dr. Cowles presented an interesting paper on the mechanism of 
insanity, which elicited a valuable discussion on physical training. 

The forty-fourth meeting of the Association was held at Niagara 
Falls, June 10, 1890. Dr. H. P. Stearns, of Connecticut, was presi- 
dent. Sixty-six members were present, and 18 other persons by 
invitation. 

In obedience to the general sentiment of the Association no 
excursions or outside engagements had been arranged for, and the 
whole time was devoted to the serious work of the regular sessions. 

A paper was presented by Dr. Charles W. Page on the " Relation 
of Attention to Hypnotic Phenomena." It may be remembered that 
at this time much popular interest had been excited by the observa- 
tions in France as to the benefits of hypnotism in the treatment of 
various morbid mental conditions. 

Dr. Carlos F. MacDonald read a paper on recent legislation for 
the insane in the State of New York, which occasioned a discussion 
upon methods of admission to institutions and also upon the 
government and administration of institutions. 

Dr. Wey presented a paper on physical training as a means of 
mental improvement, which brought out many instructive facts as 
to the practice in different institutions for the insane. 

A resolution was adopted expressing the gratification of the 
members of the Association that the State of New York had passed 
a law to provide state care for all of her dependent insane. It was 



48 INSTITUTIONAL CARE OF THE INSANE 

further added, as the opinion of the Association, that the principle 
that the insane are the wards of the state should be universally 
recognized and members should labor earnestly for the adoption of 
smiilar legislation throughout the country. 

An exciting discussion occurred upon politics in asylums, but no 
action was taken. One member of the Association announced that 
he was in favor of the political control of institutions ; otherwise, 
the sentiment seemed to be unanimously against it. 

A lengthy discussion also occurred upon the topic " Are Hos- 
pitals for the Acute Insane only Desirable ?" The sentiment seemed 
to be in favor of the present large hospitals with different depart- 
ments for different classes. 

Dr. Cowles read a paper upon training schools for nurses among 
the insane, which gave valuable information as to the method of 
organizing such schools. 

A report was received from a committee appointed at a previous 
meeting in reference to the publication of a manual of post-mortem 
examinations for the use of institutions. Dr. Blackburn, of the 
Government Hospital for the Insane, was asked to prepare such a 
manual and the secretary was instructed to make a contract for 
printing the same. 

The forty-fifth meeting of the Association was held at Wash- 
ington, May 28, 1891. Dr. Daniel Clark, of Ontario, was president. 
Ninety-two members were present. 

The most important subject for consideration at this meeting 
of the Association was the reorganization of its work in order to 
secure a more compact and efficient organization. The general 
sentiment seemed to be that instead of being an association of 
superintendents of institutions for the insane, it should become an 
association for the treatment of the insane and the study of insan- 
ity. A resolution was adopted appointing a committee of 13 mem- 
bers to revise and expand the constitution and by-laws and to 
formulate a plan to be considered and adopted at the next meeting 
of the Association. 

The forty-sixth meeting of the Association was also held in 
Washington, on May 3, 1892. Dr. J. B. Andrews was president. 
Seventy-two members were present, and a large number of visitors 
by invitation. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 49 

A discussion occurred on the surgical treatment of insanity, 
epilepsy and other nervous diseases which was participated in by 
many members and a large number of specialists. 

Professor Donaldson, of Clark University, presented an inter- 
esting paper on the results of the study of the brain of the well- 
known Laura Bridgeman, who was blind, deaf and dumb and 
nearly destitute of the sense of smell and taste. 

The Committee on Reorganization presented a plan of reorgan- 
ization, together with a constitution and by-laws, which was care- 
fully considered and adopted. It provided for a board of coun- 
sellors, for active, associate and honorary members, and also 
arranged for the publication of a volume of transactions. 

APPENDIX. 

Project of the Law Adopted by the Association in 1868. 

Preamble. — The Association of Medical Superintendents of American 
Institutions for the Insane, believing that certain relations of the insane 
should be regulated by statutory enactments calculated to secure their rights 
and also the rights of those entrusted with their care, or connected with 
them by ties of relation, or friendship, as well as to promote the ends of 
justice, and enforce the claims of an enlightened humanity, for this purpose 
recommend that the following legal provisions be adopted by every state 
whose existing laws do not, already, satisfactorily provide for these great 
ends : 

1. Insane persons may be placed in a hospital for the insane by their 
legal guardians, or by their relatives, or friends, in case they have no 
guardians ; but never without the certificate of one or more reputable 
physicians, after a personal examination, made within one week of the date 
thereof ; and this certificate to be duly acknowledged before some magis- 
trate, or judicial officer, who shall certify to the genuineness of the signa- 
ture, and to the respectability of the signer. 

2. Insane persons may be placed in a hospital, or other suitable place 
of detention, by order of a magistrate, who, after proper inquisition, shall 
find that such persons are at large, and dangerous to themselves or others, 
or require hospital care and treatment, while the fact of their insanity shall 
be certified by one or more reputable physicians, as specified in the preceding 
section. 

3. Insane persons may be placed in a hospital, by order of any high 
judicial officer, after the following course of proceedings, viz.: On state- 
ment in writing, of any respectable person, that a certain person is insane, 
and that the welfare of himself, or of others, requires his restraint, it shall 
be the duty of the judge to appoint, immediately, a commission, who shall 
inquire into and report upon the facts of the case If, in their opinion, it 



so INSTITUTIONAL CAKE OF THE INSANE 

is a suitable case for confinement, the judge shall issue his warrant for such 
disposition of the insane person as will secure the objects of the measure. 

4. The commission provided for in the last section shall be composed of 
not less than three nor more than four persons, one of whom, at least, shall 
be a physician and another a lawyer. In their inquisition they shall hear 
such evidence as may be offered touching the merits of the case, as well 
as the statements of the party complained of, or of his counsel. The party 
shall have seasonable notice of the proceedings, and the judge is authorized 
to have him placed in suitable custody while the inquisition is pending. 

5. On a written statement being addressed, by some respectable person, 
to any high judicial officer, that a certain person, then confined in a hospital 
for the insane, is not insane, and is thus unjustly deprived of his liberty, the 
judge, at his discretion, shall appoint a commission of not less than three 
nor more than four persons, one of whom, at least, shall be a physician 
and another a lawyer, who shall hear such evidence as may be offered touch- 
ing the merits of the case, and, without summoning the party to meet them, 
shall have a personal interview with him, so managed as to prevent him, 
if possible, from suspecting its objects. They shall report their proceedings 
to the judge, and if, in their opinion, the party is not insane, the judge shall 
issue an order for his discharge. 

6. If the officers of any hospital shall wish for a judicial examination of 
a person in their charge, such examination shall be had in the manner pro- 
vided in the fifth section. 

7. The commission provided for in the fifth section shall not be repeated, 
in regard to the same party, oftener than once in six months ; and in regard 
to those placed in a hospital under the third section, such commission shall 
not be appointed within the first six months of their residence therein. 

8. Persons placed in a hospital under the first section of this act, may be 
removed therefrom by the party who placed them in it. 

9. Persons placed in a hospital under the second section of this act, may 
be discharged by the authorities in whom the government of the hospital is 
vested. 

10. All persons whose legal status is that of paupers, may be placed in a 
hospital for the insane by the municipal authorities who have charge of 
them, and may be removed by the same authority, the fact of insanity, being 
established as in the first section. 

11. On statement, in writing, to any high judicial officer, by some friend 
of the party, that a certain party, placed in a hospital under the third sec- 
tion, is losing his bodily health, and that consequently his welfare would be 
promoted by his discharge, or that his mental disease so far has changed its 
character as to render his further confinement unnecessary, the judge shall 
make suitable inquisition into the merits of the case, and, according to its 
result, may or may not order the discharge of the party. 

12. Persons placed in any hospital for the insane, may be removed there- 
from, by parties who have become responsible for the payment of their 
expenses ; provided, that such obligation was the result of their own free 




DR. SAMUEL BAYARD WOODWARD. 



ASSOCIATION OF MEDICAL SUPERINTENDENTS 5 1 

act and accord, and not of the operation of law, and that its terms require 
the removal of the patient in order to avoid further responsibility. 

13. Insane persons shall not be made responsible for criminal suit, unless 
acts shall be proved not to have been the result, directly or indirectly, of 
insanity. 

14. Insane persons shall not be tried for any criminal act during the 
existence of their insanity; and for settling this issue, one of the judges 
of the court, by which the party is to be tried, shall appoint a commission, 
consisting of not less than three nor more than five persons, all of whom 
shall be physicians, and one, at least, if possible, an expert in insanity, who 
shall examine the accused, hear the evidence that may be offered touching 
the case, and report their proceedings to the judge, with their opinions 
respecting his mental condition. If it be their opinion that he is not insane, 
he shall be brought to trial ; but if they consider him insane, or are in doubt 
respecting his mental condition, the judge shall order him to be placed in 
some hospital for the insane, or some other place favorable for a scientific 
observation of his mental condition. The person to whose custody he may be 
committed, shall report to the judge respecting his mental condition, pre- 
vious to the next term of court ; and if such report is not satisfactory, the 
judge shall appoint a commission of inquiry, in the manner just men- 
tioned, whose opinion shall be followed by the same proceedings as in 
the first instance. 

15. Whenever any person is acquitted in a criminal suit, on the ground 
of insanity, the jury shall declare this fact in their verdict; and the court 
shall order the prisoner to be committed to some place of confinement, for 
safe keeping, or treatment, there to be retained until he may be discharged 
in the manner provided in the next section. 

16. If any judge of the highest court having original jurisdiction shall be 
satisfied, by the evidence presented to him, that the prisoner has recovered, 
and that the paroxysm of insanity in which the criminal act was committed, 
was the first and only one he had ever experienced, he may order his uncon- 
ditional discharge; if, however, it shall appear that such paroxysm of 
insanity was preceded by at least one other, then the court may, in its 
discretion, appoint a guardian of his person, and to him commit the care 
of the prisoner, said guardian giving bonds for any damage his ward may 
commit : Provided, always, that in case of homicide or attempted homi- 
cide, the prisoner shall not be discharged, unless by the unanimous con- 
sent of the superintendent and the managers of the hospital, and the 
court before which he was tried. 

17. If it shall be made to appear to any judge of the supreme judicial 
court, or other high judicial officer, that a certain insane person is mani- 
festly suffering from the want of proper care, or treatment, he shall order 
such person to be placed in some hospital for the insane, at the expense of 
those who are legally bound to maintain him. 

18. Application for the guardianship of an insane person shall be made to 
the judge of probate, or judge having similar jurisdiction, who, after a 
hearing of the parties, shall grant the measure, if satisfied that the person 



52 INSTITUTIONAL CARE OF THE INSANE 

is insane, and incapable of managing his affairs discreetly. Seasonable 
notice shall be given to the person who is the object of the measure, if at 
large, and if under restraint, to those having charge of him ; but his presence 
in court, as well as the reading of the notice to him, may be dispensed with, 
if the court is satisfied that such reading, or personal attendance, would 
probably be detrimental to his mental or bodily health. The removal of the 
guardianship shall be subjected to the same mode of procedure as its 
appointment. 

19. Insane persons shall be made responsible, in a civil suit, for any injury 
they may commit upon the person or property of others ; reference being 
had in regard to the amount of damages, to the pecuniary means of both 
parties, to the provocation sustained by the defendant, and any other cir- 
cumstance which, in a criminal suit, would furnish ground for mitigation 
of punishment. 

20. The contracts of the insane shall not be valid, unless it can be shown, 
either that such acts were for articles of necessity, or comfort, suitable to 
the means and conditions of the party, or that the other party had no reason 
to suspect the existence of any mental impairment and that the transaction 
exhibited no marks of unfair advantage. 

21. A will may be invalidated on the ground of the testator's insanity, 
provided it be proved that he was incapable of understanding the nature 
and consequences of the transaction, or of appreciating the relative values 
of property, or of remembering and calling to mind all the heirs-at-law, or 
of resisting all attempts to substitute the will of others for his own. A will 
may also be invalidated on the ground of tlie testator's insanity, provided it 
be proved that he entertained delusions respecting any heirs-at-law, calcu- 
lated to produce unfriendly feeling towards them. 



III. 

THE AMERICAN MEDICO-PSYCHOLOGICAL 
ASSOCIATION 1893-1913. 

The forty-seventh meeting- of the Association and the first 
under its new name of " The American Medico-Psychological 
Association," was held at Chicago, June 6, 1893. Dr. J. B. 
Andrews was president. Eighty-seven members were present, 
and nine persons by invitation. 

The address of the president referred to a number of important 
subjects. Among them were suggested the desirability of a uni- 
form course of study in training schools for nurses and attend- 
ants in hospitals ; the better promotion of education in psychiatry 
and the relation of state institutions to political control. 

Owing to the desire of the vice-president, Dr. Curwen, not to 
become president until the fiftieth anniversary of the founding of 
the Association in 1894, Dr. Andrews was re-elected president for 
another year. 

Dr. Wise presented a paper on hopeful recoveries from insanity. 

Dr. Matthew D. Field, of New York, in an interesting paper, 
called attention to the fact that the condition known in institutions 
among the insane as " hsematoma auris " which had been regarded 
by many alienists as peculiarly belonging to the insane was not 
unknown to the ancients. He gave an account of the deformity 
appearing in the ears of the statue of an athlete discovered in Rome 
in 1887; and stated that similar deformities were not uncommon 
among acrobats, boxers, football players and school children whose 
ears had been subjected to violence. He also stated that similar 
deformities were found in the lower animals, especially in hunting 
dogs. He did not believe that the condition arose from a single 
blow but was due to repeated injuries. In the discussion which 
followed the impression seemed to be that the writer did not fully 
account for its great prevalence among the insane, especially among 
those who suffered from epilepsy and other degenerative troubles, 
not necessarily the result of violence or traumatism. 
9 



54 IN'STITUTIONAL CARE OF THE INSANE 

A paper was presented by Dr. Fisher, of Boston, upon " The 
New Boston Insane Hospital," in which he recommended that the 
title asylum and the word insane in the hospital be removed so that 
the stigma which is thus placed on institutions for the insane be 
done away with. He recommended the erection of two-story 
pavilion buildings upon the slow combustion or mill construction 
plan in cottages, which are self-contained, that is, provided with 
kitchen and dining-room. In the discussion it was evident that the 
trend of public sentiment seemed to be in favor of cheaper cottage 
buildings for the chronic insane. 

A paper was also presented by Dr. N. Emmons Paine on 
instruction in psychiatry in the American medical schools. 

Although the meeting was the forty-seventh in point of time, it 
occurred upon the forty-ninth year of the establishment of the 
Association. Commencing with the fiftieth year the newly organ- 
ized American Medico-Psychological Association decided to pub- 
lish an annual volume of transactions to contain a full record of 
the proceedings and papers of the Association. 

The Association convened to celebrate the fiftieth year of its 
establishment in Philadelphia, May 15, 1894. Dr. Curwen was 
president. Ninety-eight members were present. 

The principal event of the sessions was the address of the 
president, in which he gave a careful retrospect of the history 
of the Association during the previous 50 years. He also gave 
sketches of the lives and services of many of the men with whom 
he had been associated during that period. There were several 
historical addresses ; one by Dr. Edward Cowles, " The Progress 
of the Care of the Insane During the Half Century " ; another by 
Dr. W. W. Godding, of Washington, " The Development of the 
Present Hospital for the Insane " ; a third by Dr. G. Alder Blumer, 
"A Half Century of American Medico-Psychological Literature " ; 
and a fourth by Dr. T. W. Fisher, " New England Alienists During 
the Past Half Century." 

Dr. S. Weir Mitchell in the annual address made severe criti- 
cisms upon the management of institutions for the insane through- 
out the country. He believed that boards of managers were not 
well constituted and that institutions were lacking in proper facili- 
ties for the care of the patients, or for the study of mental diseases. 
He deplored the absence of trained nursing, and urged the need of 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 55 

electrical equipment, of hydro-therapeutic apparatus, and of lab- 
oratories. As he spoke before the Association by special invitation 
as a representative of the medical profession of Philadelphia, where 
the Association had been organized 50 years before, the members 
as courtesy demanded listened patiently to his arraignment and 
made no reply. 

During the following year, however, several articles from mem- 
bers appeared in medical journals challenging the correctness of 
his conclusions; and all felt that they were unjust. The ultimate 
efifect of the address was undoubtedly good and stimulated the 
newer men to greater activity in strictly medical lines. 

A most useful paper was presented by Dr. J. W. Babcock, of 
South Carolina, on " Provision for Tuberculosis in Hospitals for 
the Insane," in which for the first time in the history of the Associa- 
tion the careful separation of tubercular from other patients was 
advocated, and the necessity of an absolute disinfection of rooms 
occupied by tuberculous patients to prevent the spread of the dis- 
ease to other patients was insisted upon. This was the beginning 
of the widespread movement in the institutions to segregate the 
tuberculous in order to safeguard the health of other patients. 

The fifty-first meeting of the Association was held in Denver, 
at the Brown Palace Hotel, in June, 1895. ^^- Edward Cowles, of 
Massachusetts, was president. Forty-four members and several 
trustees of institutions were present. 

The presidential address related to " The Advancement of 
Psychology in America." 

This was followed by an excellent paper from Dr. P. M. Wise 
on "Medical Work in Wards of Hospitals for the Insane." The 
discussion of this paper was unusually full and interesting. 

A paper was also presented by Dr. George H. Rohe, on "Pelvic 
Disease in Women and Insanity," which elicited much discussion. 

The fifty-second meeting of the Association was held at Boston, 
in 1896. Dr. Richard Dewey was president. One hundred and 
twenty-two members were present and 18 guests and visitors by 
invitation. 

A report on training schools was presented which recommended 
the preparation and publication of a manual for the instruction of 
nurses. Although this recommendation was adopted the manual 
was never prepared. 



56 INSTITUTIONAL CARE OF THE INSANE 

A committee on the preparation of statistical tables presented a 
report accompanied by forms which were ordered printed for con- 
sideration at the next session. These forms were never adopted. 

The presidential address of Dr. Dewey voiced the general senti- 
ment that Dr. Mitchell's address of two years before had done 
scant justice to the work of the Association. 

The annual address on " Psychological Education " was by 
President G. Stanley Hall, of Clark University. 

An interesting paper was presented by Dr. Carlos F. MacDonald 
on " State Care and Maintenance for the Dependent Insane in New 
York." 

There was also a valuable paper by Dr. Frederick Peterson on 
the " Psychology of the Idiot." 

The fifty-third meeting was held at Baltimore, on May Ii, 1897. 
Dr. T. O. Powell was president. Ninety members were present and 
many other persons as guests and visitors by invitation. 

One of the most important addresses was that of the president, 
entitled : " A Sketch of Psychiatry in the Southern States." Dr. 
Powell had taken great pains to collect information as to the early 
history of many institutions and to preserve such traditional details 
as can only be furnished by men who were familiar with the early 
history of the dififerent states. 

An interesting discussion occurred upon "After-Care of the 
Insane," initiated by Dr. Richard Dewey, of Wisconsin, and par- 
ticipated in by Drs. Hill, Godding, Gilman and Hoyt. A resolution 
was adopted favoring the movement, and requesting the president 
to appoint a committee upon after-care to co-operate with a similar 
committee of the American Neurological Association. 

A paper was presented by Dr. P. M. Wise on "Training Schools 
for Nurses in Hospitals for the Insane." 

There were also papers on "The Medical and Material Aspects 
of Industrial Employment for the Insane," by Dr. G. Alder Blumer, 
and on " Commitment and Detention of the Insane," by Dr. E. N. 
Brush. 

The annual address was given by Dr. Bernard Sachs, of 
New York, on " Advances in Neurology and Their Relation to 
Psychiatry." 

The fifty-fourth annual meeting of the Association was held at 
St. Louis, May 10, 1898. The president was Dr. R. M. Bucke, of 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 57 

Canada. Sixty members were present, and 13 other representatives 
of institutions, visitors and guests were present by invitation. 

The presidential address by Dr. Bucke was on "Surgery Among 
the Insane in Canada," which gave an account of surgical work 
which had been done principally upon women in his institution at 
London, Ont. He was of the opinion that much benefit had 
resulted from surgical operations in gynecological diseases, and 
recommended that an effort be made to extend the work to other 
similar institutions in Canada. 

The annual address was delivered by Dr. J. T. Eskridge, of 
Colorado, on " The Relations Between Alienists and Neurologists 
in the Study of Psychiatry and Neurology." The paper was of 
unusual interest because it was the first presented before the Asso- 
ciation which foreshadowed the requirements of the present inten- 
sive scientific study of insane conditions. He believed that there 
should be one resident physician for every 25 patients, and also a 
psychologist, pathologist, medical director and a training school 
for nurses in every hospital for the insane. At the time the address 
was delivered the proposition seemed to be an ideal absolutely 
unattainable ; in the light of present conditions it does not seem 
visionary. 

There were papers on " The Care of the Chronic Insane," by 
Drs. H. A. Oilman and B. D. Eastman; also on " The Wisconsin 
County Care System," by Dr. W. B. Lyman. The discussions were 
full and interesting. 

The fifty-fifth meeting of the Association was held in New York, 
May 23, 1899. Dr. Henry M. Hurd, of Maryland, was president. 
One hundred and fifty-three members were present, also 23 other 
persons connected with institutions as visitors and guests by 
invitation. 

The presidential address was on " The Teaching of Psychiatry." 
The annual address, delivered by Dr. Frederick Peterson, of New 
York, was on " The Problems of Psychiatry." It was an earnest 
plea for psychopathic hospitals where insanity could be treated in 
its early stages, and the disease more carefully studied; also for 
the establishment of colonies. He urged that institutions for the 
chronic insane should be made more attractive and that occupation 
should be furnished for patients. 

A paper was presented by Dr. Carlos F. MacDonald on " Legal 
Versus Scientific Tests of Insanity in Criminal Cases." 



58 INSTITUTIONAL CARE OF THE INSANE 

Dr. John B Chapin, of Philadelphia, presented a paper on the 
" Psychology of Criminals," which contained a plea for better 
medical service in prisons. 

Dr. G. Alder Blumer presented a paper on " The Care of the 
Insane in Farm Dwellings." 

The fifty-sixth meeting of the Association was held at Rich- 
mond, Va., May 22, 1900. Dr. Joseph G. Rogers, of Indiana, was 
president. Ninety-eight members were present, also 23 trustees 
and other persons representing institutions. 

The address of the president was on " A Century of Hospital 
Building for the Insane," in which he gave the results of his large 
experience as a builder of hospitals, not only as to plans and dis- 
tribution of buildings, but also as to the material to be used in 
building and the manner of construction. He entered into details 
as to floors, wall surfaces, woodwork, doors, window-sashes, lights 
and systems of heating and ventilation. The address was of great 
interest and value. 

The annual address was given by Dr J. Allison Hodges, of Rich- 
mond, upon " The ElTect of Freedom Upon the Physical and Psy- 
chological Development of the Negro," in which he took a dis- 
couraging view of the future of the race. His conclusions were 
that the negro was " designed by God and nature to remain a white 
man's servant," and must be kept in a condition of peonage and 
training until he acquired the qualities which he lacked. 

Many papers were presented but most of them related to details 
of treatment. 

The fifty-seventh meeting of the Association was held at Mil- 
waukee, Wis., June 11, 1901. Dr. P. M. Wise, president of the 
New York State Lunacy Commission, was president. Eighty 
members were present, also 29 persons interested in the care of the 
insane and other guests. 

The address of the president, which was general in character, 
urged the establishment of psychopathic hospitals for the treatment 
of acute cases. He expressed the opinion that the present system 
of committing patients to institutions prevented the majority of 
incipient cases from being placed where proper treatment and relief 
could be obtained at a time when it was possible to do them good. 
This was the first official statement to this efifect made before the 
Association by a presiding officer. 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 59 

The annual address was delivered by Professor W . P Lombard, 
of the University of Michigan, on the "Reinforcement and Inhibi- 
tion of Nervous Processes." 

There was also a special paper by Dr. W. J. Mayo, of Rochester, 
Minn., on " Limitations of Surgical Work for the Insane," in 
which he gave the results of his experience in the operative treat- 
ment of traumatic epilepsy. The general conclusions were not 
favorable to surgical operations as curative measures in epilepsy. 

Dr. Henry C. Baldwin, of Boston, presented a paper on the 
" Need of Better Provision for the Care of Cases of Delirium 
Tremens and of Doubtful Mental Disease," which contained a plea 
for the establishment of a special institution in each city, either as a 
separate hospital or in connection with general hospitals, for the 
care of such cases. In the discussion which followed a general 
approval was given of the proposal, and mention was made of 
several cities where such provision already existed. 

A paper was also presented by Dr. D. R. Brower on the treat- 
ment of acute insanity in special wards in general hospitals, in 
which he urged that admission to such wards should be as free as 
that of other patients In the discussion which followed it was evi- 
dent that the proposition did not meet with general approval, and 
some members seemed to think that the construction of such hos- 
pitals might be viewed as a criticism upon existing hospitals for 
the insane. In reply Dr. Brower said that whatever criticism might 
be made, it was evident that the proposition to establish such hos- 
pitals had already taken hold upon the public mind, and that in the 
future they would undoubtedly be established — a prophecy which 
has already been realized. 

The fifty-eighth meeting was held at Montreal, June 17, 1902. 
Dr. R. J. Preston, of Virginia, was president. Eighty-six mem- 
bers were present, and 23 physicians, trustees, medical officers or 
visitors were present by invitation. 

The address by the president was upon " The Development of 
the Care of Mental Diseases in the United States and Canada." 
Among many other interesting statistics were the following : 

The population of the United States at the close of the ninth census of 
the eighteenth century (1790), just after the ratification of the Constitution 
by the 13 original states, was something near four millions. Three addi- 
tional states (Vermont, Kentucky and Tennessee) were admitted during 



6o INSTITUTIONAL CARE OF THE INSANE 

the last decade of the eighteenth century, and at the beginning of this * cen- 
tury the population had increased to five and one-third millions, or 35.10 
per cent. In the first decade only one state (Ohio) was admitted, but the 
population had increased to nearly seven and one-third millions, or 36.38 
per cent. During the second decade five states (Louisiana, Indiana, Missis- 
sippi, Illinois and Alabama) were admitted, and the population had increased 
to over nine and one-half millions, or 33.07 per cent. During the third 
decade two states (Maine and Missouri) were admitted, and the population 
had increased to a little over twelve and two-thirds millions, or 33.88 per 
cent. In the fourth decade two states (Arkansas and Michigan) were 
admitted, and the population had increased to a little over seventeen mil- 
lions, or 32.67 per cent. In the fifth decade four states (Florida, Texas, 
Iowa and Wisconsin) were admitted, and the population had increased to 
a little over twenty-three millions, or 35.87 per cent. In the sixth decade 
three states (California, Minnesota and Oregon) were admitted, and the 
population had increased to nearly thirty-one and one-half millions, or 
35.58 per cent. In the seventh decade four states (Kansas, West Virginia, 
Nevada and Nebraska) were admitted, and the population had increased to 
over thirty-eight and one-half millions, or 22.63 per cent. In the eighth 
decade only one state (Colorado) was admitted, but the population had 
increased to a little over fifty millions, or 30.08 per cent. In the ninth 
decade four states (North Dakota, South Dakota, Washington and Mon- 
tana) were admitted, and the population had increased to over sixty-two 
and one-half millions, or 24.86 per cent. In the tenth decade three states 
(Wyoming, Utah and Idaho) were admitted, and the population had 
mcreased to over seventy-five and one-half millions, or 26.84 per cent. Con- 
sidering this wonderful growth from 16 states and a population of 5,308,483 
the first year of this century, to 45 states and a population of 75,694,764 at 
the close of the last year of the nineteenth century, what may we not expect 
for the incoming century? 

During the third decade, the second, third and fourth state asylums to be 
established in the United States were the Eastern Asylum, Lexington, Ky., 
opened in 1824, the South Carolina Asylum, Columbia, opened in 1828, and 
the Western Asylum, Staunton, Va., opened in 1828. During the fourth 
decade six state asj^lums were opened. During the fifth decade nine state 
and four private asylums for the insane were opened. 

In 1850 the insane population in state institutions was given at 15,610. 
During the sixth decade 19 state and five private asylums were opened, 
and the insane population had increased to 24,042, or 54 per cent. During 
the seventh decade 21 state and six private asylums were opened, and the 
insane population had increased to 37,432, or 55 per cent. During the eighth 
decade 31 state and ten private asylums were opened, and the insane popula- 
tion had increased to 9i,959, or 145 per cent. During the ninth decade 37 
additional state and 17 private hospitals were established, and the insane 
population had increased to 106,485, or 16 per cent. During the tenth decade 
21 additional state and 28 private hospitals were opened. 

' The Nineteenth Century. 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 6l 

The first asylum for the insane in Canada, the Provincial Asylum, at St. 
John, N. B., was opened November 14, 1835. 

In the fifth decade, to use dates corresponding with those in the United 
States, two asylums for the insane were opened, the Provincial Asylum, 
Toronto, Can., opened June 31, 1841, and the Beauport Asylum, of Quebec, 
opened in 1845. At the beginning of the nineteenth century (1800) the 
population of Canada was 240,000. At the beginning of the fifth decade 
(1840) the population of Canada was less than one million. 

During the sixth decade two hospitals for the insane were opened, Rock- 
wood Hospital, Ontario, 1855, and Nova Scotia Hospital, Halifax, N. S., 
1858. 

During the seventh decade (1861 to 1871) two asylums were opened at 
Quebec, in 1868, and London Asylum, London, Ont., in 1870. The popula- 
tion of Canada in 1871 was 3,485,751. 

During the eighth decade five asylums were opened, Provincial Asylum, 
New Westminster, B. C, 1873 ; Asile de St. Jean de Dieu, Longue Pointe, 
Que., rebuilt, 1873 ; St. Julien Asylum at St. Ferdinand, Que., 1873 ; Hamil- 
ton Asylum, Hamilton, Ont., 1876; Hospital for Feeble-Minded, Orillia, 
Ont., 1876; Prince Edward Island Hospital, Charlottetown, P. E. I., 1879. 
The population in 1881 was 4,324,810. 

During the ninth decade two asylums were opened. Homewood Retreat, 
Guelph, Ont., 1883 ; Selkirk Asylum, Selkirk, Man., 1885. The population 
in 1891 was 4,833,239. 

During the tenth decade (1891 to 1901) four asylums were opened, 
Protestant Asylum, at Verdun, near Montreal, 1890 ; Brockville Asylum, 
Brockville. Ont., 1894; Asj'lum for the Insane, Brandon, Man., 1891 ; Asylum 
for the Insane, Cobourg, Ont., 1901. The population in 1901 w^as 5,338,893. 
There are at this time 16 hospitals for the insane in Canada or British 
America. 

The annual address was delivered by Professor Wesley Mills, 
of McGill University, on " Reflexes and Their Psychiatric Cor- 
relatives." This lecture was illustrated by many lantern slides, and 
was of true scientific value. 

An important paper was presented by Dr. Emmett C. Dent, of 
New York, on " Hydriatic Procedures an Agency in the Treat- 
ment of Insanity." It gave interesting historical details as to the 
employment of water, and also entered into careful descriptions 
of the methods used and spoke of the great importance of water 
as a therapeutic agent. In the discussion which followed it was 
made apparent that many institutions had established hydro- 
therapeutic outfits and that great advantage had come to patients 
from their use. 

Dr. Owen Copp, of Massachusetts, gave an excellent paper on 
the results and possibilities of family care of the insane in Massa- 



62 INSTITUTIONAL CARE OF THE INSANE 

chusetts, which eHcited a discussion and indicated that the mem- 
bers of the Association were not agreed upon the advisabiHty of 
family care. 

Papers on " Tent Life for the Uncleanly Insane," by Dr. Wright, 
and " Tent Life for the Tubercular Insane," by Dr. Haviland, 
were presented. 

The fifty-ninth meeting of the Association was held in Wash- 
ington, May 12, 1903. 

The president was Dr. G. Alder Blumer, of Rhode Island. One 
hundred and ninteen members were present, and 24 persons repre- 
senting boards and others interested in the treatment of the insane 
were present as guests by invitation. 

The presidential address related largely to certain movements in 
progress in various states to improve the care of the insane. The 
president deprecated the evils of centralization in the control of 
institutions, and also suggested certain measures which were cal- 
culated to prevent the increase of insanity, such as the prevention 
of marriages of consanguinity, the exclusion of defective emi- 
grants and the prohibition of the marriage of feeble-minded 
persons. 

There was no annual address. An interesting feature, however, 
was a personal reminiscence by Dr. Stephen Smith, of the late 
Amariah Brigham, entitled: "How Dr. Brigham Met the Chal- 
lenge to Diagnose Insanity at Sight." 

A symposium was held upon the status of the insane criminal, 
after the reading of papers by Dr. H. E. Allison, entitled : " Hos- 
pital Provision for the Insane Criminal" ; by Dr. Frank W. Robin- 
son, " Recognition of the Insane in Penal Institutions," and by Dr. 
Robert B. Lamb, " The Mind of the Criminal." The discussion 
was valuable as presenting the great need of careful attention to 
the mental condition of persons in penal institutions, and the grow- 
ing conviction that many convicts were mentally defective or 
insane. 

An interesting paper was presented by Drs. Wright and Havi- 
land, entitled " Additional Notes Upon Tent Treatment." 

The first paper to be presented to the Association on " Blood- 
Pressure " was by Dr. William Rush Dunton, Jr. 

Dr. L. Pierce Clark presented an account of the newest psy- 
chopathic hospital at Kiel, Germany. 



AMERICAN MEDICO-PS VCHOLOGICAL ASSOCIATION 63 

In the business sessions of the Association after discussion and 
general consideration of the subject, it was voted that the Asso- 
ciation become a member of the Congress of American Physicians. 
This action required that the Association should meet every third 
year in Washington. 

The sixtieth meeting of the Association was held in St. Louis, 
May 30, 1904. Dr. A. B. Richardson, of Washington, who had 
been elected president, died in the interval between his election 
and taking office. The vice-president. Dr. A. E. Macdonald, of 
New York, was accordingly elected to fill the vacancy. Eighty- 
seven members were present at the meeting, and 14 visitors and 
guests by invitation. 

The presidential address by Dr. Macdonald related to topics 
of general interest in the care of the insane. 

The annual address, given by Dr. Charles G. Chaddock, of St. 
Louis, was a review of the relations of the mind and the nervous 
system. 

A paper presented by Dr. E. Stanley Abbott, of the McLean 
Hospital, gave an account of the rapid extension of observation 
wards and psychopathic hospitals in this country and abroad. 

x\n interesting paper on the training of nurses was presented by 
Dr. C. P. Bancroft, in which he presented a plan for the better 
training of nurses for the insane. 

A paper by Dr. George T. Tuttle, of the McLean Hospital, on 
" Hydrotherapy," gave many practical details as to its employ- 
ment in institutions. 

The sixty-first meeting of the Association was held at San 
Antonio, Texas, April 18, 1905. Dr. T. J. W. Burgess, of Mon- 
treal, was president, and Dr. E. C. Dent, who had been elected to 
succeed Dr. Burr, was secretary. 

Forty-eight members were present, also 39 visitors and guests 
were registered. 

The presidential address was on " The Insane in Canada," and 
gave a review of the conditions in the diflFerent provinces of 
Canada. The statistics as to the number of insane were very 
interesting : 

In 1901, according to the census of that year, there were in the Dominion 
of Canada 16,622 persons of unsound mind, being a ratio of 3.125 per thou- 
sand, or about i in every 319 of a population numbering 5,318,606 souls, 
exclusive of the unorganized territories. Of these 16,622 defectives, 10,883 



64 INSTITUTIONAL CARE OF THE INSANE 

were inmates of asylums or other institutions, making a percentage of .642 
per cent under care. 

The provinces as regards the number of their insane stood as follows : 
Prince Edward Island 361, a proportion of 3.496 per thousand ; Ontario 
7552, or 3.459 per thousand; New Brunswick 1064, or 3.213 per thousand; 
Quebec 5297, or 3.212 per thousand; Nova Scotia 1403, or 3.052 per 
thousand; Manitoba 464, or 1.818 per thousand; British Columbia 301, or 
1.684 pei" thousand; Northwest Territories 180, or 1.132 per thousand. 

With respect to custodial care, British Columbia ranked first, having 
under care at the close of 1901 no less than 94 per cent of the total number 
of those mentally incapacitated ; Manitoba came next with "j"] per cent in 
safe-keeping; Nova Scotia stood third with 71 per cent sheltered; Ontario 
was fourth with 69 per cent in asylums; Prince Edward Island was fifth 
with 61 per cent provided for ; Quebec and Northwest Territories were 
equal with 58 per cent under care ; and New Brunswick was eighth with 
52 per cent housed. 

The following table shows the changes indicating increased custodial 
care, or otherwise, on the part of the several provinces, in the decade 
extending from 1891 to 1901. By this it will be seen that there had been 
a marked advance in all with the exception of New Brunswick, which 
remained unchanged : 

Provinces. In Asj^lum 18 

British Columbia 90 per cent 

Manitoba 55 " 

New Brunswick 52 " 

Nova Scotia 36 " 

Ontario 58 " 

Prince Edward Island 38 " 

Quebec 50 " 

Northwest Territories (housed 
in Manitoba asylums) .... 



In Asylum 1901 


94 per 


cent 


n " 




52 " 




71 " 




69 " 




61 " 




58 " 




58 " 


« 



Canada 54 per cent 66 per cent 

He further deplored the fact that Canada had been made the 
dumping- ground for defective emigrants, and gave in support of 
this statement the following statistics : 

In proof that what I have said is no exaggeration of the ill effects attend- 
ant upon immigration insufficiently safeguarded, let me call your attention 
to some figures bearing on the subject. By the census of 1901 the population 
of Canada was 5,371,315, the number of foreign-born being 699,500; the 
total of the insane was 16,622, and of these 2878 were foreigners. From 
these returns it will be seen that a little over 13 per cent of the general popu- 
lation — that is to say, the imported element — furnished over 17 per cent 
of so-called Canadian lunacy. Stated in another form, if the native Cana- 
dians alone are considered, there is i insane person in every 339 of the 
population ; while tlic proportion among the foreign element is i in every 
243- 



AMERICAN MEDICO-rSYCHOLOGICAL ASSOCIATION 65 

If further evidence were needed I would say that during the year 1903 
there were admitted to Canadian asylums 2213 insane persons. Of this 
number 1726 were born in Canada. The remaining portion, 487, repre- 
senting 22 per cent of the admissions, was foreign-born. At Verdun, 2148 
patients have been received since the opening of the establishment, and of 
this number 40 per cent were of foreign birth. In the same institution there 
are at present time no less than 30 persons in a population of 460, who, if 
subjected to anything but the most cursory examination, would never have 
been allowed to set foot in the country. 

He also deprecated the prevalence of political control, and said 
that in the 18 hospitals of Canada the superintendents of 12 owed 
their appointment to political influence rather than to their attain- 
ments in psychiatry. 

The annual address was presented by Dr. J. T. Searcy on 
" Tripartite Mentality," and was metaphysical in character. 

Papers were presented by Dr. H. W. Miller on " Huntingdon's 
Chorea " ; by Dr. Arthur W. Hurd on " Korsakoff's Psychosis." 

An interesting- paper on " The Relations of Surgery to Insan- 
ity " was presented by Drs. Leroy Broun and John R. Knapp. 

The sixty-second meeting of the Association was held in Boston, 
June 12, 1906. Dr. C. B. Burr, of Michigan, was president. One 
hundred and twenty-four members were present, and 81 guests 
were present by invitation. 

Owing to the death of Dr. E. C. Dent, the former secretary, Dr. 
Charles W. Pilgrim was made secretary. 

The presidential address was on " The Physician as a Char- 
acter in Fiction." 

The annual address was delivered by Prof. R. S. Woodward 
on " Psychiatry and Experimental Psychology," and was a plea 
for the study of psychiatry by the methods of experimental 
psychology. 

Several papers were presented on the subject of nurses in hos- 
pitals for the insane. Dr. Bancroft discussed women nurses in 
male wards of hospitals. Dr. Tuttle spoke of the male nurse, Dr. 
C. R. Woodson of night nursing for the insane, and Dr. R. B. 
Lamb of the training school in insane hospitals. The discussion 
of these papers showed that great improvements had been made in 
the nursing of the insane, and the training of both men and women 
as nurses during the past few years. 



66 INSTITUTIONAL CARE OF THE INSANE 

Dr. Copp presented a paper on " Further Experience in Family 
Care of the Insane in Massachusetts." 

Dr. George A. Smith gave a valuable paper on the " Cottage 
System." 

Dr. John Koren, in a paper on the statistics of the insane, spoke 
of the difficulty which he met in his endeavor to make use of the 
statistical details in hospital reports. He deplored their lack of 
uniformity, the over elaboration of trivial details, and the large 
mass of material which could not be used. He believed that the 
assigned causes of insanity were fanciful and the statistics of 
recoveries were not reliable. It is much to be regretted that this 
paper bore no fruit. 

The sixty-third meeting of the Association was held at Wash- 
ington, May 7, 1907. Dr. Charles G. Hill, of Maryland, was presi- 
dent. Eighty members were present, and 38 visitors and guests of 
the Association. 

Before the completion of its session, the Association adjourned 
to reconvene at the Jamestown Exposition, and the meetings of 
the last day were held there. 

The presidential address of Dr. Hill had for its subject "How 
Can We Best Advance the Study of Psychiatry ?" In this he made 
a plea for a more intensive study of mental disease, and of the 
effects and abuses of remedies. He believed that in medical educa- 
tion greater attention should be given to diet, the digestion of 
food, the chemical composition of food, the production of phy- 
siologic sleep, etc., and that a practical application of mental 
therapy would much increase the usefulness of institutions. 

A most important paper was a report of a committee on training 
schools for nurses, in which practical suggestions were made as 
to the organization of schools, the qualifications of pupils, the 
compulsory education of all persons engaged in nursing service, 
and the instruction of attendants who are not fitted to join the 
school and who do not undertake responsible nursing work. The 
committee believed that nurses should have a knowledge of 
anatomy, physiology and psychology, personal hygiene, the germ 
theory of disease, the appearance of drugs and their methods of 
administration and their effects, also a practical knowledge of 
cooking for the sick, massage, hydrotherapy, and the more com- 
mon medical and surgical diseases, including contagious diseases, 
the diseases of children, nervous diseases and insanity. It was 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 6/ 

also recommended that nurses should learn general as well as 
special nursing, the former in general hospitals ; that instruction 
should be given by lectures, demonstrations, etc. ; that there should 
be rotation in the various branches of service ; that the proficiency 
of pupils should be tested by examination ; and that the length of 
the course should be at least two years, and preferably three years. 
A preliminary course of instruction was also suggested. A 
diploma should finally be given to every nurse who completes the 
course. 

Two important papers on after-care of the insane were pre- 
sented by Dr. Robert M. Elliott and Dr. William Mabon respect- 
ively. In the discussion which followed several instances were 
cited of the benefit which had followed after-care. 

Three papers were presented on reception hospitals and psy- 
chopathic wards by Drs. Adolf Meyer, C. P. Bancroft and M. S. 
Gregory. In the discussion of the papers much additional infor- 
mation respecting the success of efforts to establish such wards 
in Canada, Michigan, Ohio and Iowa was elicited. 

An interesting paper was presented by Dr. Alfred I. Noble, of 
Michigan, on " Shorter Hours for Nurses," in which he recom- 
mended that the nurse's day be eight hours, and that her time be so 
arranged as to secure the maximum of service at a time when it 
was most required by patients. 

The sixty-fourth meeting of the Association was held at Cin- 
cinnati, Ohio, May 12, 1908. The president was Dr. C. P. Ban- 
croft, of New Hampshire. Ninety-one members were present, and 
29 visitors and guests of the Association. 

The presidential address of Dr. Bancroft was entitled " Hopeful 
and Discouraging Aspects of Psychiatric Outlook." He believed 
that the remarkable scientific study of psychiatry during the past 
few years had accomplished great good, as also the especial atten- 
tion given to sociology and to the treatment of insanity. He 
believed that improvements had occurred in buildings, in better 
training of nurses, in the establishment of psychopathic wards and 
in improved methods of teaching psychiatry. He expressed the 
opinion that a clearer understanding of the etiology of insanity 
emphasized the importance of more strict and careful attention 
to the prevention of mental disease. He recommended a closer 
medical inspection of prisons and jails and greater care to prevent 
the admission of undesirable emigrants. He also recommended 



68 INSTITUTIONAL CARE OF THE INSANE 

that efiforts be made by the Association to place medical expert 
testimony on a higher plane. 

The annual address was delivered by Hon. Jndson Harmon, 
Governor of Ohio. It was general in character but contained 
excellent suggestions as to the improvement of expert testimony. 

A pathological paper was presented by Drs. Southard and 
Mitchell, which gave an anatomical analysis of cases of insanity 
with reference to the incidence of arteriosclerosis, senile atrophy 
and the distribution of pigments in brain tissue. 

Dr. Ferris, president of the New York Lunacy Commission, 
presented a paper on Italian immigration and insanity. 

Dr. B. T. Sanborn, of Maine, presented interesting data in ref- 
erence to insanity in the rural districts of Maine, from which it 
appeared that insanity in Maine was diminishing, a fact which he 
ascribed in part to a prohibitory law. In the discussion which fol- 
lowed Dr. Mitchell stated that at the Bangor Insane Hospital 
alcoholic insanity existed in less than 5 per cent of the men 
admitted, while at Dan vers Hospital 18 per cent or 20 per cent of 
such cases were admitted. He believed that a lack of foreign 
immigration had much to do with the diminution of insanity in 
the State of Maine. 

The sixty-fifth meeting of the Association was held at Atlantic 
City in June, 1909. Dr. Arthur F. Kilbourne, of Minnesota, was 
president. One hundred and twenty-one members were present, 
and 38 guests and trustees by invitation. 

Owing to the recent illness of the president no presidential 
address was presented. 

The annual address was by Prof. I. Woodbury Riley, of Vassar 
College, Poughkeepsie, N. Y., on " Mental Healing in America." 
He gave a sketch of the different forms of mental healing, includ- 
ing New Thought, Christian Science, and what has been known as 
the Emmanuel Movement. He closed with an appeal to the Asso- 
ciation to educate the public and to lead it away from a blind wor- 
ship of magic in medicine, and to revive the teachings of the early 
American schools, especially that of Rush, which emphasized the 
co-ordinate study of the mind as well as of the body. 

An interesting paper was presented by Dr. John B. Chapin on 
the " Insanity Defense for Crime." 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 69 

Dr. Ferris, president of the New York Lunacy Commission, pre- 
sented a paper on " Border-Land Cases of Insanity and the Volun- 
tary Patient," one of the first papers to be presented upon the sub- 
ject. This elicited considerable discussion and brought out the 
fact that in New York, Massachusetts, Maryland and Minnesota 
provision already existed for the admission of voluntary patients. 

An interesting paper was presented by Drs. C. H. Lavinder, C. 
F. Williams, and J. \V. Babcock on the prevention of pellagra in 
the United States. 

Two pathological papers were also presented, one by Dr. 
McGaffin entitled " Anatomical Analysis of 70 Cases of Senile 
Dementia" ; the other by Dr. E. E. Southard on " Anatomical 
Findings in Senile Dementia." 

The sixty-sixth meeting was held at Washington, May 3, 1910. 
Dr. W. F. Drewry, of Virginia, was president. One hundred and 
twenty-four members were present, and 31 visitors and guests by 
invitation. Dr. Charles G. Wagner was made secretary in place of 
Dr. C. W. Pilgrim, who had been elected vice-president. 

In the presidential address on " The Scope of the Activities of 
the Alienists," eugenics, the restriction of alcoholic excesses and 
abuses, and the better regulation of social diseases were discussed. 

The annual address by Professor A. F. Dressier, of Alabama, 
was on " The Psychology of Superstition." 

The Committee on Expert Testimony presented an elaborate 
report in which it was recommended that in the presentation of the 
hypothetical question the evidence on both sides should always be 
included. It was also recommended that there should be consulta- 
tions between medical witnesses as to the mental status of a patient 
suspected of insanity. In doubtful cases it was recommended that 
the question of insanity be tested by a period of hospital observa- 
tion for a longer or shorter time, as the best method of arriving 
at the truth. 

Following this Dr. C. F. MacDonald presented an excellent 
paper on the " Ethical Aspects of Expert Testimony." 

Dr. Austin Flint, of New York, presented a paper on " Methods 
of Dealing with the Criminal Insane." 

A departure in the papers usually presented was a paper on 
" Military Psychiatry," by Dr. R. L. Richards, of the United 



70 INSTITUTIONAL CARE OF THE INSANE 

States Army Medical Corps, then detailed for service in the Gov- 
ernment Hospital at Washington. 

There were also two papers on pellagra, one by Dr. J. W. Bab- 
cock and the other by Dr. M. L. Perry. 

The sixty-seventh meeting of the Association was held at Den- 
ver, Colo., June 19, 191 1. Dr. Charles W. Pilgrim, of New York, 
was president. Fifty-eight members were present, and 19 visitors 
and guests of the Association. 

The presidential address was on the "Care and Treatment of 
the Insane in the State of New York." It was an interesting 
record of the development of state care. Very appropriate tributes 
were also paid to eminent men, now deceased, who had been con- 
nected with New York institutions. 

The annual address was delivered by Hon. Alva Adams, of 
Colorado. 

An important paper by Dr. Robert L. Richards was " A Study 
of Military Offenses Committed by the Insane in the United States 
Army During the Past Fifty Years." This paper brought clearly 
before the Association an aspect of insanity and feeble-mindedness 
which had never been previously considered in this country, and 
emphasized the important part played by congenital weak-minded- 
ness and mental defects in the offenses often punished in the army. 

Allied to it also was a paper by Dr. W. W. Richardson, of Penn- 
sylvania, on " Imprisonment Psychoses," with illustrative cases. 

There was also an interesting series of papers on pellagra, by 
Drs. E. B. Saunders and J- W. Babcock, of South Carolina; on 
" The Treatment of Pellagra," by Dr. C. C. Bass ; " Pellagra, in its 
Relations to Insanity and Nervous Diseases," by Dr. J. W. Mobley, 
of Georgia, and on " The Rapid Spread of Pellagra in the United 
States," by Dr. George A. Zeller, of Illinois. 

In the ])aper by Dr. Babcock it was made evident that the dis- 
ease had existed in South Carolina for many years. He presented 
the facsimile of a record of it in 1834 at the South Carolina State 
Hospital. 

The paper by Dr. Bass was based largely upon the theory that 
pellagra was due to an infectious toxin generated in spoiled corn. 

Dr. Mobley did not believe that the disease was due to a toxin 
from corn, but rather to a variety of causes acting upon the nerv- 
ous system. 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 7I 

The paper by Dr. Zeller indicated that pellagra was much more 
prevalent in the Northern states than had heretofore been sup- 
posed. 

The sixty-eighth meeting of the Association was held at Atlan- 
tic City, May 28, 1912. Dr. Hubert Work, of Colorado, was 
president. One hundred and twenty-three members of the Asso- 
ciation were present, and 38 visitors, officers of institutions and 
guests by invitation. 

The presidential address was " Psychologic Aspects of Insanity 
and Allied Defects." It contained a strong appeal for greater 
effort on the part of the Association to promote the study of 
eugenics, and touched upon several preventive measures of a 
surgical character which have not yet met the approval of all 
physicians. 

The annual address by Hon. Herbert P. Bissell, of New York, 
was entitled " A Layman's View of the Care and Treatment of 
the Insane in the State of New York." which contained many his- 
torical and interesting details as to the present methods employed 
in the institutions of that state. 

An interesting paper was presented by Dr. James V. May, of 
New York, on "Immigration as a Problem in State Care of the 
Insane," which led to the appointment of a committee to prepare a 
memorial to be laid before Congress. 

Dr. Richard Dewey, of Wisconsin, presented an interesting 
account of the " Jury Law for the Commitment of the Insane in 
Illinois," together with some account of ^Irs. E. W. Packard, its 
author, and the later lunacy legislation in Illinois. This was fol- 
lowed by an interesting discussion upon the commitment of the 
insane. 

An interesting symposium occurred upon " The Diversional 
Occupation of the Insane," " The Re-education of Dementia 
Praecox Cases," " The Industrial Training of Chronic Cases," and 
the " Occupational Nurse." These papers were by Drs. Herring, 
Haviland, LaMoure and Dunton. 

There were two interesting pathological papers by Drs. Orton 
and Fuller, of Massachusetts. 

An interesting and unusual paper upon " Insanity Among 
Indians " was presented by Dr. H. R. Hummer, Superintendent of 
the Government Hospital for Insane Indians in North Dakota. 



72 INSTITUTIONAL CARE OF THE INSANE 

There was also a valuable paper on "The Treatment of the 
Insane in British Columbia," by Dr. Charles A. Doherty. 

The sixty-ninth meeting of the Association was held at Niagara 
Falls, Canada, June lo, 1913. Dr. James T. Searcy, of Alabama, 
was president. One hundred and thirty-eight members were pres- 
ent, and 55 trustees, medical officers and visitors were present by 
invitation. 

The presidential address by Dr. Searcy was on the topic, " Have 
We a Specialty?" in which he reviewed the work of those inter- 
ested in the treatment of insanity, in the study of backward chil- 
dren, the feeble-minded and imbecile, and in the effects of drugs 
and alcoholics upon the race, and showed the great importance of 
such study for all men engaged in treating insanity. 

The annual address was by Dr. Edward Ryan, of Kingston, 
Ont., upon " The More Modern Work of Institutions for the 
Insane." 

An important paper on the " Statistical Study of the Insane," 
by Dr. James V. May, of the New York State Hospital Commis- 
sion, analyzed the recent statistics of the State of New York. In 
the year 191 1 the statistics gathered by the New York State Hos- 
pital Commission were so arranged as to become of great value to 
the state in their representation of what was actually happening to 
the insane. The statistics for the years 191 1 and 1912 showed that 
the ratio of insane in New York to the general population was i 
to 282 ; the ratio of males being i to 293 ; and of women i to 269. 
This preponderance of women in institutions was ascribed to the 
greater longevity of women owing to the facts that alcoholic 
psychoses and general paresis were diseases which prevailed very 
much more largely among men than women. Two hundred and 
ninety-seven voluntary patients had been admitted during the year, 
of which 129 were readmissions. Of the 297 voluntary patients, 
53 were subsequently committed to institutions. The number of 
patients discharged on parole from the various institutions during 
the year was 905. The number of criminal insane in state hos- 
pitals was 4 per cent of the population. The insane population in 
the state in 1912 was 31,624. The increase from 1890 to 1900 had 
been at the rate of 47.7 per cent. During the same period the 
general population had increased 21.2 per cent. From 1900 to 19 10 
the increase of insanity was 37.8 per cent, while the increase of 



AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION 73 

general population had been 25.4 per cent. From 1910 to 1912 the 
population of the state had increased more rapidly than the 
census of the insane. Of 4046 discharges during 1912, 1610 
were regarded as recovered. The recovered per 100 admissions 
during the year was 21.9 per cent. Of 7283 admissions during the 
year 52.39 per cent were of native birth, and 47 per cent were of 
foreign birth; 22.12 per cent were of native parentage, and 73.29 
per cent were of foreign or mixed parentage, and 4 per cent were 
of unknown parentage. Of the patients of foreign birth 23.1 per 
cent were born in Ireland ; 15.3 per cent in Germany ; 13.6 per cent 
in Russia; 9.8 per cent in Italy; 8.4 per cent in Austria; 5.6 per 
cent in England ; 4.4 per cent in Hungary ; 3.7 per cent in Canada ; 
2.1 per cent in Poland. 

The paper contained valuable and interesting statistics and 
closed with a plea for the adoption of uniform statistics by all 
insane institutions of the different states so that the results might 
be comparable. 

A paper was presented by Dr. E. Stanley Abbott on "Psychology 
and the Medical School," which brought out strongly the fact 
that psychology was not taught as any part of the curriculum of 
the medical schools, and in but three schools was a knowledge of 
it required for entrance. 

Dr. Arthur H. Harrington presented an elaborate paper on the 
" Congregate Dining-Room and its Management," containing 
many details as to the practical management of congregate dining- 
rooms. He believed that in addition to securing greater efficiency 
in serving food they also were an excellent therapeutic measure for 
patients of all classes because they tended to establish habits of 
order and self-control. 

An important paper on " A Proposed Change in the Criminal 
Law " was presented by Dr. Charles H. North, of the Dannemora 
Criminal Hospital. In this he recommended a change of the 
ordinary pleading in cases of murder where insanity has been 
pleaded as a defense from " not guilty by reason of insanity " to 
" guilty but insane." In the discussion which followed it was 
apparent that those members who were interested in medical-legal 
questions were not prepared to accept the position taken by the 
writer. 



74 INSTITUTIONAL CARE OF THE INSANE 

A carefully prepared paper by Dr. H. J. C. Kuhlman, of Buffalo, 
was entitled " The Father Complex." It was an elaborate pre- 
sentation of the results of psycho-analysis. 

A paper by Dr. Frank Woodbury on " Benjamin Rush, the 
Patriot, Physician and Psychiatrist," was appropriate in view of 
the fact that 1913 was the centennial anniversary of his death. 

A report of the Committee on Medical and Scientific Work in 
Hospitals in the United States and Canada, prepared two years 
before by Dr. Adolf Meyer, was presented for publication in the 
Transactions. The investigation covered an inquiry into the gen- 
eral type of organization for the care of the insane in the various 
states, and a special inquiry into methods of medical care. The 
committee expressed the opinion that in states where a special com- 
mission existed there was the best showing in the work of indi- 
vidual institutions. The committee also believed that there was a 
decided growth in the direction of hospital rather than custodial 
care. The fact that the number of physicians was obviously too 
small in many institutions to do the work required by modern 
psychiatry was deplored. The conclusions of the committee in 
reference to the nursing problem were not definite. The committee 
deplored the lack of ef^cient after-care and preventive work. 

Several sample reports of institutions had been prepared for 
presentation in connection with the report, but unfortunately they 
had been lost in transmission and could not be reproduced. 



IV. 

THE AMERICAN JOURNAL OF INSANITY. 

In May, 1844, Dr. Amariah Brigham, the first superintendent of 
the State Lunatic Asylum at Utica, wrote to Dr. Pliny Earle, 
then superintendent of the Bloomingdale Asylum, a letter making 
the following announcement : 

I am about starting an American journal of insanity, quarterly, octavo, 
96 pages, edited by the officers of this asylum. The first number will be out 
early in July. It is intended for the general reader as well as for the pro- 
fession. This is a strict secret as I have mentioned it to no one but Dr. 
Beck, of Albany. 

The projected American Journal of Insanity appeared in accord- 
ance with Dr. Brigham's plan in July, and was the first journal in 
the English language founded at private expense and devoted to 
mental medicine. Dr. Blumer well remarks : 

In view of the multiplicity of his duties as the head of a large institution 
as yet imperfectly organized as well as the precariousness of his health, it 
was a great and laudable undertaking. 

It is a matter of history that he suffered alike in pocket and in health by 
the enterprise, but he has left us a monument of his genius and energy which 
cannot fail to rebuke and incite those who in the face of pressing adminis- 
trative work too prone to find an excuse for the sacrifice of professional 
aspirations and a plea of literary and scientific indolence.* 

This Journal soon became the organ of the whole specialty of 
insanity in this country. It reported the papers and discussions of 
the Association and served to concentrate and strengthen the 
spirit of scientific investigation. Dr. Brigham, notwithstanding his 
ill health, edited the Journal for four years. Upon his death the 
managers of the Lunatic Asylum assumed the responsibility of its 
publication, and placed it in the hands of Dr. T. Romeyn Beck, of 
Albany, one of their number, who edited it with great efficiency 
until 1855. 

Dr. Beck was a man of unusual literary and scholarly qualifica- 
tions, and the Journal under his guiding care lost some of its 
former popular features and became a more scholarly publication. 

^ Am. Journal of Insanity, Vol. 51, p. 40, 1894. 



76 INSTITUTIONAL CARE OF THE INSANE 

In the year 1855, by the resignation of Dr. T. Romeyn Beck and 
the appointment of Dr. John P. Gray as superintendent of the New 
York State Lunatic Asylum, the latter became the editor of the 
Journal. He was not a man of large scholarship or of any unusual 
literary training, but was eminently a forceful personality, with 
strong and decided views as to all matters of public policy in the 
care of the insane. During the succeeding 30 years he conducted 
the Journal largely as a personal organ for the promulgation of 
his own personal views. He had much able assistance in editorial 
work and broadened the scope of the periodical by devoting a 
greater degree of attention to medico-legal, therapeutical and 
pathological matters and accomplished much good work. He had 
an eager mind and was ambitious for the development of his 
work, but was at all times intolerant of the views of others. He 
filled a large place in the history of New York for more than a 
quarter of a century and for many years dominated public opinion. 
In the Journal he advocated mechanical restraint, approved of 
the so-called Utica crib, opposed separate provision for the 
chronic insane, favored the construction of the hospital for insane 
criminals in connection with the Auburn State Prison, contended 
fiercely for the purely physical basis of insanity, violently opposed 
the doctrine of moral insanity, advocated the teaching of psychia- 
try in the medical schools ; and was the first among American 
superintendents to encourage pathological research in his institu- 
tion. During a portion of his editorship the Journal failed, by 
reason of his pronounced views, to secure the active co-operation 
of men like Pliny Earle, Isaac Ray, Edward Jarvis or Luther V. 
Bell, and became increasingly the organ of the so-called " Utica 
School." He had the assistance of Drs. Cleveland, Kellogg, 
Andrews, Kempster, Kitchen, Pilgrim, Blumer, Brush and other 
equally able men in the conduct of the Journal. 

The successor of Dr. Gray was Dr. G. Alder Blumer who, in 
1886, entered upon the duties of editor with much enthusiasm. 
He changed the form of the Journal, added to its departments and 
broadened its scope. He introduced letters from foreign corre- 
spondents, and systematized the collection of news items from 
the different institutions of the country, and thus enabled all insti- 
tutions to announce to the public what they were doing and to 
learn what others were doing. The Journal became consequently 



AMERICAN JOURNAL OF INSANITY "JJ 

the organ of the whole Association to an extent which had never 
obtained before. 

At the time when the institutions of New York were placed 
under the control of the Lunacy Commission there developed a 
possibility that the Journal might become the organ of the new 
commission, and in a measure cease to represent the profession 
of the entire United States. The Council of the Association con- 
sequently, after negotiation with the managers of the Utica State 
Hospital, purchased the Journal and arranged for its conduct by 
a Board of Three Editors, Edward Cowles, of Boston ; Henry M. 
Hurd, of Baltimore, and Richard Dewey, of Chicago, managing 
editor. The office of publication of the Journal was removed to 
Chicago in 1894, and three annual volumes were published under 
Dr. Dewey's editorship. 

Unfortunately, an extreme pressure of other imperative work 
compelled him to retire from the position and a new Board of 
Editors, consisting of G. Alder Blumer, of Providence; E. N. 
Brush, of Baltimore; J. Montgomery Mosher, of Albany, and 
Henry M. Hurd, of Baltimore, was appointed by the Council. 
The office of publication was then removed to Baltimore and 
placed in charge of The Johns Hopkins Press, the publication 
agent of The Johns Hopkins University. Later Charles K. Clarke, 
of Toronto, was added to the board to represent Canada. For 
seven years the managing editor of the Journal was Dr. Henry M. 
Hurd, but he retired in 1904, and Dr. E. N. Brush assumed the 
duties and has continued managing editor until the present time. 

During the past 25 years a notable change has taken place in 
the contents of the Journal. The large number of semi-popular 
papers which formerly appeared in its pages has given place to 
articles of a more scientific type, such as descriptions of forms of 
mental disease, descriptions of pathological processes, and valuable 
contributions to the pathology of insanity. The Journal has never 
been a source of income to the Association and in fact has been 
published at a small annual financial loss. It has, however, exer- 
cised an important influence in consolidating public opinion 
throughout the entire profession of mental medicine, and has thus 
wielded a decided influence in matters of public policy. In review- 
ing the pages of the Journal of Insanity during its existence of 
nearly 70 years one is impressed with the extent and variety of the 



7© INSTITUTIONAL CARE OF THE INSANE 

material appearing therein, and the influence which it had upon 
the growth and development of an enlightened sentiment in behalf 
of the insane in the United States. It is possible to trace in its 
pages the distinct trend of important currents of public opinion 
which have developed from time to time throughout the country. 
In the early history of the Journal its pages were mainly occupied 
with considerations of mental disease and its treatment. An 
endeavor in fact was made by the first editor, Dr. Brigham, to 
gather as much material as possible from every quarter in refer- 
ence to insanity. He collected and printed, for example, the 
descriptions of insanity contained in the plays of Shakespeare and 
the works of other poets ; and gathered statistics as to the existence 
and extent of mental disease in foreign countries. The incidence 
of suicide throughout the country was carefully considered and 
an effort was made to gather adequate statistics from every state. 
The best methods of caring for patients were studied as also the 
best organization of institutions for the insane. It was evidently 
the intention of the editor to make the Journal of Insanity a popu- 
lar journal to diffuse knowledge about the insane throughout the 
entire country, with special reference to the instruction of the 
medical profession. In the five volumes edited by Dr. Brigham it 
is of interest to note the extent and variety of his personal com- 
munications to the Journal. He reviewed the reports of institu- 
tions; gathered interesting items about insanity from literature, 
current publications and text-books; corresponded with his pro- 
fessional associates in reference to mooted points in psychiatry, 
and when absent from home visited institutions for the insane and 
described them. Even when journeying in search of health he 
sought out such institutions, both public and private, in various 
states from New York to Mexico, and in his letters gave many 
acute and valuable criticisms upon their condition. It is evident 
that he was not so much a profound student of mental disease as 
one interested in the social and humane aspects of insanity. Had 
he lived it is probable that the Journal would have retained its 
semi-popular character and may have remained in closer touch 
with the medical profession of the United States. 

The present Board of Editors is composed of G. Alder Blumer, 
Edward N. Brush, Charles K. Clarke, Henry M. Hurd and J. 
Montgomery Mosher. Edward N. Brush has been for ten years 
managing editor. 



CHAPTER II 

EARLY LEGISLATION FOR THE INSANE 



I. 

EARLY AND COLONIAL CARE OF THE INSANE. 

To all who have considered the intimate relations of insanity 
and pauperism, especially under the conditions of pioneer life, 
where no machinery had yet been established to enable the state 
to carry out its obligations to the dependent classes, it will not 
appear strange that few references to the dependent insane occur 
in the early laws of the colonies. There is reason to believe in fact, 
that little legislation existed on the subject, and that most of the 
records that pertain to it have been lost. 

In subsequent chapters the early care of the insane in the older 
colonies and states has been gone into somewhat in detail. It has 
been thought wise, however, to give in the following pages a brief 
account of the early efforts in behalf of the insane as regards the 
colonies at large. 

In New England it is probable that the care of the insane, owing 
to the complexity of township organization, devolved upon the 
townships or the town councils of the different villages and towns, 
and that insane persons only came to the notice of the public 
authorities when they were indigent and needed charitable assist- 
ance. Where they were members of wealthy families, who were 
able to secure personal care and nursing for them, little thought 
seems to have been given to their existence. The dependent insane 
were classed as paupers, but were regarded as special objects of 
charity. 

When we remember the conditions of comparative poverty in 
which the early colonists lived, it is not surprising that special pre- 
caution should be taken lest wandering individuals, destitute of 
any claim upon public charity, might gain a residence which would 
give rise to future trouble by their dependent condition. It is in 
this regard that we find in 1639 the first reference to any law of 
settlement in Massachusetts, when the power to determine the 
settlement of any person requiring public relief was given to the 
general court, or to any two magistrates out of court. In 1645, it is 



82 INSTITUTIONAL CARE OF THE INSANE 

Stated that " Mr. Shepheard, John Johnston and Captain Wiggin " 
were chosen a committee to consider the law " for disposing of 
inmates and settling impotent (feeble mentally?) aged persons or 
vagrants." Again in 1655 each town was authorized to " refuse 
admission to persons from other towns in the colony." All persons 
were to be considered town charges and no one was to receive aid 
directly from the general treasury of the colony. It was also 
enacted that " three months' quiet, undisputed residence gave a 
settlement." 

The earliest record of any legislation regarding the insane in 
Massachusetts is a law, passed in 1676, which delegates to the 
selectmen the care of the person and estate of the dependent insane. 

In 1694, in " An Act for the Relief of Idiots and Distracted Per- 
sons," the care of the insane is given to the selectmen and overseer 
of the poor, but the disposition of their property is given to the 
justice of the peace. 

In 1736 the first reference to methods of determining the insan- 
ity of the individual is found in a law giving power to the judge 
of probate, on the request of friends or the overseers of the poor, 
to direct the selectmen to make inquisition, the final decision, how- 
ever, seeming to depend upon the opinion of the selectmen or over- 
seers of the poor and the judge. 

In 1784 an act was passed in regard to guardianship of the 
insane, and in 1798 a law which permitted such lunatics as were 
" furiously mad, so as to render it dangerous to the safety or the 
peace of the good people to be at large," to be committed to the 
House of Correction. 

The next legislation is found in 181 1, when the Massachusetts 
General Hospital was incorporated and the McLean Hospital was 
established, it being subsequently opened in 18 18. 

Despite the fact that the early settlers of Rhode Island were 
very poor, one of the earliest records as regards the insane, which 
is quoted in full elsewhere,' is from Rhode Island, dated November 
II, 1650, and contains a touching appeal to the Town Council of 
Providence from that stern Puritan, Roger Williams, on behalf of 
a Mrs. Wilson, whom he describes as a " distracted woman " and 
for whom he urges them to make provision, " remembering," he 
concludes, " that we know not how soon we ourselves may be 

' Care of the Insane in Rhode Island, Vol. III. 



EARLY AND COLONIAL CARE OF THE INSANE 83 

deprived of our reason — except mercy from ye God of Mercies 
prevent it." 

A little more than a year later, there is a record of an order 
authorizing the town council to take charge of the person and 
property of one Margaret Goodwin, " during her distraction," and 
requiring it to account for its disposition of her estate. 

During the next 50 years records of similar orders are to be 
found at intervals. 

In 1725, the first law was passed for the care of the insane, by 
which the inland towns were empowered to build houses of cor- 
rection for vagrants, " and to keep mad persons." In 1742 a law 
was passed giving to the town council the care of all insane and 
imbecile persons, with power to appoint guardians for their estates. 

In 1828 the Dexter Hospital was opened, and gave accommoda- 
tion to a small number of insane from Providence exclusively. On 
December i, 1847, the " Butler Asylum for the Insane " w^as 
opened. 

In Connecticut the tow^n system of relief for the poor was almost 
universal and aid was dispensed by the selectmen of the towns, as 
these officials were familiar with the actual home conditions of 
those who required public support. 

The first record of public relief for the insane in Connecticut is 
to be found in the records of the Colony of New Haven for 1645, 
where a patient is stated to have been partially relieved in her home. 
In 1648 an additional record is made that the same person had been 
cared for in the home of the marshal, w'ho asked to be relieved of 
her care. 

In 1655 was passed the first law of settlement of paupers, which 
undoubtedly included the insane, although they were not so speci- 
fied until later. In 1673 the general court ordered each town to 
care for its own poor, but provided that a town might escape the 
responsibility of strangers by warning them to depart within three 
months of their arrival. 

In 1699 the General Court of Connecticut passed " An act for 
relieving idiots and distracted persons," which copied verbatim 
the provisions of the Massachusetts law of 1694. In 171 1 another 
law was passed entitled " An act to provide in case of sickness, 
including insanity, feeble-mindedness and similar conditions." 



84 INSTITUTIONAL CARE OF THE INSANE 

In 1727 the number of disorderly persons in Connecticut had 
become so large that a colony workhouse was built to which all 
disturbers of the public peace were to be committed, as well as 
" persons under distraction and unfit to go at large, whose friends 
do not care for their safe settlement." 

In 1 71 5 a law had been passed providing that the relations of the 
insane, within certain specified degrees of consanguinity, should 
assume the duty of providing for them, a fine of 20 shillings being 
imposed for failure to comply with this requirement, the money 
to be applied to the support of the insane relative in question. This 
law was amended in 1739, 1745, 1750 and 1784, all the amendments 
being directed more to the protection of property belonging to the 
insane than to their personal safety and comfort. 

In 1793 a law was passed by which it became the duty of the 
county authorities and selectmen of the town of residence to order 
a dangerous insane person to be confined in a suitable place, the 
county jail if necessary. At the same time the authority to com- 
mit an insane person to the workhouse was repealed. In 1797 the 
section concerning the confinement in jail was also revoked. 

In 1824 a law was passed whereby any citizen could complain to 
one of the civil authorities, or to the selectmen in his town, if he 
found an insane person at large. If within three days no action 
was taken under the statute he might complain under oath to any 
justice of the peace, and inform him that the person was dangerous 
and unfit to be at large. It was then the duty of the justice of the 
peace to have the said person brought before him, or some other 
justice of the peace, and if, upon inquiry, the complaint was found 
to be true, he was empowered to order the person to be confined in 
a suitable place as long as it was deemed necessary. If satisfied at 
any time that the person was no longer dangerous to go at large, 
he might order his discharge. These provisions did not apply to 
the harmless insane ; care for their safety did not come until later. 

In the period between 1793 and the founding of the Hartford 
Retreat in 1824 there was no public place in which harmless 
insane persons, not criminals, might be confined. Capen says, " it 
is hardly necessary perhaps to imagine how these unfortunates 
were cared for before the days of the improved modern asylum, 
but it may be mentioned in passing that in a memorial presented to 




II 



EARLY AND COLONIAL CARE OF THE INSANE 85 

the Assembly in 1786, Mary Weed, of Stratford, stated that for 20 
years her husband had been so insane as to be kept " chained." 

No records are available as to the care of the insane in Vermont, 
prior to the establishment, in 1834, of the Vermont Asylum for the 
Insane, now the Brattleboro Retreat. 

The first record in New Hampshire as regards legislation for the 
insane occurs in an act passed in 1714 by the colonial legislature 
of New Hampshire for the " Relief of Idiots and Distracted Per- 
sons." ^ This act is similar to those passed by other states, and 
empowered the overseers of the poor of the town where the insane 
person was born, or was by law an inhabitant, to make necessary 
provisions for " the relief, support, and safety of such impotent 
or distracted persons at the charge of the town or place whereto 
he or she of right belongs." In one respect the act dilTers from 
others of similar nature. It gave to the justices of the peace the 
power to put such insane persons to any work or service of which 
they may be capable, at the discretion of the selectmen and over- 
seers of the poor. 

This act constituted the sole legislation in behalf of the mentally 
diseased until 1767, when an act was passed entitled " An Act in 
further addition to an Act entitled ' An Act for the Relief of Idiots 
and Distracted Persons.' " This act empowered the judge for the 
probate of wills and for granting letters of administration, upon 
request of some relative, friend of any " idiot, non compos lunitick 
or distracted person, or the overseers of the poor where the said 
idiot or distracted person " lived, to make inquiry into the con- 
dition of the person in question, and to appoint a suitable guardian 
to take charge of the patient's property. 

The judge was further empowered to make inquiry in case 
anyone was suspected of embezzling or making illegal disposition 
of the property of a mental defective, and if the person so accused 
be found guilty, to commit him to prison. 

The acts of 1776 and 1791 are merely resumes of the previous 
acts. 

In 1822 a further act was passed," and in 1830 a movement was 
begun for the building of a state asylum. After many delays this 
effort proved successful and resulted in the opening on October 29, 
1842, of the New Hampshire Asylum for the Insane, at Concord. 

^ See Care of the Insane in New Hampshire, Vol. II. 
' See Care of the Insane in New Hampshire, Vol. II. 



86 INSTITUTIONAL CARE OF THE INSANE 

In New York there seems to have been very Httle early legisla- 
tion in reference to the insane, and they were probably, if depen- 
dent, classed among the poor. 

In October, 1665, an amendment to the Duke of York's laws 
provided that as distracted persons may be very chargeable and 
troublesome, and so prove too great a burden for one town to bear, 
that therefore, each town in the " rideing " where such persons 
happen to be shall contribute towards the charges which may arise 
on account of such persons. 

In 1736 a building known as the " I'ublick Workhouse and House 
of Correction of the City of New York '' was built, and in it the 
insane were confined. 

According to Mosher, the first statute in existence regarding the 
insane is a law passed in 1788, under the title " An Act for Appre- 
hending and Punishing Disorderly Persons." This act provided : 

Whereas there are persons who by lunacy or otherwise are furiously mad 
and so disordered in their senses as to be dangerous to go abroad, it shall 
be lawful for two or more justices of the peace to cause to be apprehended 
and kept safely locked up, such persons in some secure place, and if neces- 
sary to be chained there, if the place of their legal settlement be in the city 
or town within that county. 

In May, 1797, the admission of two cases of mania is noted in 
the records of the hospital in the City of New York now known as 
New York Hospital. 

In 1806 the hospital in the City of New York was authorized by 
statute to enlarge the same by erecting additions for the more con- 
venient accommodations of the sick, and particularly to provide 
suitable apartments for maniacs, adapted to the various forms and 
degrees of insanity. 

In 1827 an act w-as passed providing that " A lunatic shall not 
be confined in any prison, jail or house of correction, or confined 
in the same room with any person charged with or convicted of 
any criminal ofTense." In the revised statute of 1827 and 1828, it 
was made the duty of the overseer of the poor of the city or town 
where a lunatic was found, to apply to any two justices of the 
peace of that city or town, who, if they were satisfied that it was 
dangerous to permit the said lunatic to go at large, were required 
to issue their warrant, directed to the constable and overseer of 
the poor, commanding that they cause him to be locked up and con- 




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THE LEFT OF GENERAL HOSPITAL. 



EARLY AND COLONIAL CARE OF THE INSANE 87 

fined in some secure place, to be provided by the overseer of the 
poor. 

In 1838 county poorhouses and private and pubHc county asy- 
lums and the lunatic asylums in the City of New York were all rec- 
ognized by legislative enactment, but it is apparent that the care of 
the insane was not recognized as a public duty, except in so far as 
it was deemed desirable to protect the public from the dangerous 
tendencies of lunatics running at large, or to guard the unfortunate 
individual himself from the consequences of his mental irresponsi- 
bility. It was not until 1842 that laws were passed to erect the 
first state institution for the insane in New York. 

There is no record of any provision for the insane in New 
Jersey prior to a letter, dated July 29, 1772, from the Lords Com- 
mission of Trade and Plantations in London, to Sir William Camp- 
bell, Governor of Nova Scotia, submitting the draught of a clause 
it was proposed to insert into the king's instructions to all govern- 
ors in America, giving them, as chancellors, the power to issue 
commissions for the care and custody of idiots and lunatics. 
This clause appears to have been submitted to William Franklin, 
a son of Benjamin Franklin, at that time Governor of New Jersey, 
and it, together with his reply, dated October 12, 1772, is quoted 
in full in the chapter on the Care of the Insane in New Jersey.^ 

On November 21, 1794, the Legislature of New Jersey passed an 
act entitled " An Act for Supporting Idiots and Lunatics and Pre- 
serving Their Estates." ' This act, as well as the succeeding one of 
1804, was more concerned with the care of the property of the 
insane than the care of their persons. Again in 1818 we find a new 
act, providing in one section that idiots and lunatics shall not be 
arrested or detained in custody as criminals, and in another pro- 
vision for the apprehension and locking up, chaining if necessary, 
of " any lunatic furiously mad, or dangerous to go at large." 

It was not until 1838 that the need of an asylum for the exclusive 
care of the insane began to be felt. The agitation beginning from 
an address by Dr. L. A. Smith, delivered before the State Medical 
Association in New Brunswick in May, 1836, finally resulted, with 
the assistance of Miss Dix, in the passage on ^larch 20, 1845, o^ ^" 
act entitled " An Act to Authorize the Establishment of the New 

* See " The Care of the Insane in New Jersey " in a subsequent volume. 
' fbid. 



58 INSTITUTIONAL CARE OF THE INSANE 

Jersey State Lunatic Asylum." On May 25, 1848, the asylum was 
opened for the admission of patients. 

In 1676, in the records of the Upland Court, Delaware County, 
occurs the first mention of any provision for the insane in Pennsyl- 
vania. It concerns " Erick," son of "Jan Vornelissen," who " is 
turned quyt madd," and provides that a "small block-house " be 
built for him and a " levy be laid " to pay cost of same, and for his 
maintenance, " according to laws of ye government." ' 

The " Religious Society of Friends," at one of their monthly 
meetings in 1709, took steps for the establishment of a hospital for 
the sick and insane. This ultimately resulted in the founding of 
the Pennsylvania Hospital in 1751. Prior to that time the insane 
people were cared for in an almshouse in the vicinity of Philadel- 
phia, known as " Green Meadows." In the petition to the Assem- 
bly of 175 1, drafted by Benjamin Franklin, asking for an appro- 
priation to defray the cost of establishing the Pennsylvania Hos- 
pital, the desirability of protecting insane persons is expressly 
alleged as one of the reasons for building such a hospital. A por- 
tion of the Pennsylvania Hospital was set apart for the insane, and 
two insane patients were admitted in 1752. The records of the 
hospital contain an interesting record left by one of the trustees, 
of his impressions of the patients confined in the cells, many of 
them for long periods of years. 

In 1803 it seems to have been thought that the insane who were 
transferred from the almshouse to the Pennsylvania Hospital 
could be made as comfortable in the almshouse, and a record is 
found of their being removed to the successor of the almshouse 
mentioned above as " Green Meadows," and which was then 
located at Tenth and Pine streets. 

In the following year there is record of the erection of apart- 
ments for the treatment of the insane at the almshouse. 

In 1817, in consequence of an agitation begun in 181 1, the 
Society of Friends opened at Frankford an institution for the care 
of such of their members " as may be deprived of their reason." 
This is now the Frankford Retreat, a full history of which is given 
in a subsequent chapter. In 1836 all sectarian restrictions as to 
admission therein were withdrawn. 

From 1830 to 1834 the r>lockley Almshouse seems to have been 
regarded as the proper place for the treatment of the dependent 

' Care of the Insane in Pennsylvania. 




friends' asylum, 1818. 



EARLY AND COLONIAL CARE OF THE INSANE 89 

insane in the vicinity of Philadelphia, and one of the buildings 
belonging to the group designed for disorderly persons was appro- 
priated to their care. About the year 1850, however, a separate 
building was erected for the insane, provided with cells and all 
the old time apparatus for the care of such patients. These cells 
were finally removed about the year i860. 

In Delaware the earliest legislation in regard to the insane is 
an act of February 2, 1793, which vests in the court of chancery the 
care of all idiots and insane over the age of 21. No provision is 
made for their care, and no doubt the same condition prior to that 
date continued whereby each family cared for its own insane, 
unless they became unmanageable, in which case they were sent 
to the nearest county jail. 

In 1812 a further act was passed giving to the court of levy in 
each county the power to remove all idiots and insane from the 
county jail to their respective poor houses. 

The counties continued to care for the mentally defective up 
to 1889. On April 25 of that year the legislature passed an act, 
by virtue of which the state assumed complete charge of all insane 
and mentally defective persons. Delaware thus became the first 
state in the Union to establish state care. 

In Maryland the custody of the pauper insane and relief of the 
poor belonged to the vestries of the established church, which was 
the Church of England. After the Revolution of 1776, and the 
consequent dissolution of the relations between the parish vestries 
and the state, the duty of such relief was committed to newly 
established boards of overseers of the poor, which, being no longer 
coterminous with the parish, became officials of the whole county. 

An examination of the Acts of the Assembly of Alaryland 
reveals the fact that about 1773, poorhouses, almshouses or work- 
houses were established in four counties of the state, under the 
supervision of directors of the poor. These poorhouses were 
designed for the poor and needy, who required charitable attention 
and support, and also for the idle, the vicious, the dissolute, and the 
disorderly, but there were, no doubt, many instances where insane 
people, incapable of much self-control, were regarded as dis- 
orderly. 

In the Acts of the Assembly of 1791 we find that the justices of 
Prince George County were authorized to levy a tax for the main- 



90 IXSTITUTIONAL CARE OF THE INSANE 

tenance and keeping of Mary Brown and her daughter, Eleanor 
Love. The laws of 1793 contain a petition of Juliana Fowler for 
the support of her daughter, who was "deprived of the use of her 
reason." In these and numerous similar petitions of the same 
period, the reason given for seeking assistance is always the same, 
namely, the desire to avoid sending an insane relative to the county 
poorhouse, against which there was evidently a strong prejudice. 

The first act providing for a state institution for the insane was 
passed on January 20, 1797.^ It resulted, with the help of the City 
of Baltimore and of private citizens, in the erection of a '' Lunatic 
and General Asylum," built on a plot of ground that now composes 
part of the site of The Johns Hopkins Hospital. In 1808 the hos- 
pital was leased by Drs. James Smythe and Colin Mackenzie, and 
was used by them and their successors for the care of the insane 
as well as of general patients. At various times the legislature 
made appropriations for its improvement, and in 1834 the state 
asserted its right to the hospital, and by legislative enactment 
devoted it to the exclusive use of the insane. 

The successor of the hospital is now known as Spring Grove 
State Hospital, located at Catonsville, about seven miles from 
Baltimore. 

In Virginia, as in Maryland, the custody of the pauper insane 
and the relief of the poor belonged to the vestries of the established 
church, which was the Church of England, until the Revolution of 
T776 dissolved the relation between church and state. 

To Virginia, however, belongs the honor of providing the first 
state hospital in America, used exclusively for the insane. This 
was " The Public Hospital for Persons of Insane and Disordered 
Minds," now the Eastern State Hospital at Williamsburg. It was 
incorporated in 1768. In 1769 the House of Burgesses passed an 
act " To make provisions for the support, and maintenance of 
idiots, lunatics and other persons of unsound mind." ' This act 
appointed trustees, and made provision for the building and main- 
tenance of the hospital, as well as rules for the admission of 
patients. A building was accordingly built, and the first patients 
admitted in October, 1773. We find in the records further laws 
pertaining to the hospital during the years between 1776 and 1790. 

* See Care of the Insane in Maryland. 
' See Care of the Insane in Virginia. 




X 



EARLY AND COLONIAL CARE OF THE INSANE 9I 

This hospital was also the first in the country to care for the 
colored insane. 

On January 22, 1825, the legislature passed an act providing for 
the erection of another hospital to be built west of the Blue Ridge. 
This institution was opened on July 25, 1828, and is now known as 
the Western State Hospital for the Insane, at Staunton, Va. 

There are apparently no records available as to the early care 
of the insane in North Carolina prior to the visit of Miss Dix, 
which resulted in an act of the Legislature of 1849, establishing 
a state hospital at Dix Hill, near Raleigh, named in honor of 
Miss Dix. 

According to Babcock, the public charity of South Carolina 
dates from the permanent settlement of Charleston, and had for its 
basis the " Poor laws of England." Acts for the maintenance of 
the poor are found in 1722, 1737, 1738 and 1751. One of the most 
interesting sections of the act of 1751 provided for subsistence of 
slaves, who may become " lunaticks " while belonging to persons 
too poor to care for them. This appears to be the earliest legal 
recognition of the insane in South Carolina. 

" The Fellowship Society of Charles Town," ' established in 
1762 and incorporated in 1769, had for its object the founding of 
an infirmary " for the reception of lunatics and other distempered 
persons in the province." There is no record, however, that the 
hospital was ever built. 

In 1808 judges of the Court of Common Pleas were vested with 
the same power as courts of equity, to inquire into cases of lunacy 
or idiocy, and to appoint guardians for them. According to Mills 
there seems to have been a poorhouse and asylum ( for lunatic per- 
sons) situated at the corner of Queen and Mazyck streets, which 
had been founded at a very early period. 

On December 21, 1821, the General Assembly passed an act 
authorizing the erection of a lunatic asylum to be combined with a 
school for the deaf and dumb. This resulted in the erection of the 
present State Hospital of South Carolina, which was opened for 
the admission of patients in December, 1828. 

There are apparently no available records as to the care of the 
insane in Georgia prior to a paragraph in the annual message 
of Governor Wilson Lumpkin to the Georgia Legislature on 

^ Now known as Charleston, S. C. 
12 



92 INSTITUTIONAL CARE OF THE INSANE 

November 4, 1834. No action was taken until 1837, i" which year 
the le.c^islature made an appropriation for building an asylum. 
This asylum was opened for the admission of patients in Decem- 
ber, 1842, and is now known as the Georgia State Sanitarium at 
Milledgeville. 

This comprises the history of the early care of the insane in the 
13 original colonies. The histories of the care of the insane in the 
newer states will be found in subsequent volumes dealing with the 
different states in detail. 




X 



II. 

THE ERA OF AWAKENING. 

The era of awakening came slowly in the United States. As has 
been stated in a previous chapter/ the insane and dependent classes 
became early identified with each other. In many Eastern states the 
only insane cared for were those already paupers and frequently, 
as in New Hampshire and Connecticut, those that were feeble and 
helpless, were bid off each year by persons who were prepared to 
assume charge of them at the lowest figure. In consequence they 
were placed in such poor and unsuitable homes as would naturally 
be furnished to them by persons who were willing to eke out a 
small income by the care of an insane person in the family. Most 
of those who were able to look after themselves were allowed to 
wander about through the country, exposed to hardships, danger 
and ill-treatment. If they were violent or destructive they were 
cared for in cages or pens in county houses or were placed in jail. 
No systematic efifort was made to assume care of any of these 
patients at a stage of their disease when they were in a condition to 
receive benefit from treatment ; they were neglected until incurable 
and when incurable were taken care of in the cheapest manner 
possible without regard to their comfort and well-being. This 
condition of afifairs existed throughout the United States and no 
state unfortunately can claim the monopoly of ill-treating the 
insane. 

The efifort made in Philadelphia in connection with the Pennsyl- 
vania Hospital for the Insane in 1751, and the establishment of the 
institution at Williamsburg, Va., in 1773, while steps in the right 
direction, cannot be considered as affording, at first, any measure 
of relief in the way of medical treatment. The term insane referred 
at that time more especially to such persons as were violent and 
required custody to prevent them from doing injurious acts toward 
their neighbors or themselves. 

At Williamsburg the medical care was confined to a non-resident 
physician who visited the institution but did not have the respon- 

* Early and Colonial Care, page 81. 



94 INSTITUTIONAL CARE OF THE INSANE 

sibility of its management. This was committed to a keeper. At 
the Pennsylvania Hospital the care of the insane was almost 
wholly custodial and for a long time, and probably until the time 
of Rush, little was attempted in the way of medical treatment. 

The department for the insane connected with the New York 
Hospital, afterwards known as the Bloomingdale Asylum, and 
now as the Bloomingdale Hospital, although housed in a separate 
building in the upper part of the city in 1821, could do little for the 
care of the indigent insane, although authorized by law to receive 
such patients; the cost of treatment was necessarily so high that 
county officials were disinclined to make contracts with it for the 
care of their insane and preferred to neglect them at home. 

A similar condition existed in regards to McLean Hospital, 
which was founded in 1818 as a department of the Massachusetts 
General Hospital, but subsequently, through the liberality of John 
McLean, erected upon a separate estate, and thus enabled to lead an 
independent existence. It did not, however, materially ameliorate 
the condition of the dependent insane. 

So also the Friends' Asylum established at Frankford, a suburb 
of Philadelphia, which, although it did excellent work in a quiet, 
unostentatious way, provided for members of the Society of 
Friends only, until 1834. 

In Connecticut, however, owing to the efforts of the State Medi- 
cal Society, a different condition prevailed. Through its efforts 
funds were furnished for the establishment of the Hartford 
Retreat. This institution was of a semi-private class, but also had 
an arrangement with the towns of Connecticut and received in- 
digent patients at a rate of payment less than the actual cost of 
treatment. It fortunately came under the guidance of Dr. Eli 
Todd, who became its first superintendent, and seems to have had a 
general interest in the better treatment of the insane throughout 
the New England states. The building of the Hartford Retreat 
directly influenced the establishment and b.uilding of the institution 
at Brattleboro, Vt. ; it also had much to do with the establishment 
of the State Asylum under Dr. Woodward, at Worcester, Mass., 
and to a less degree with the establishment of the Boston City Hos- 
pital for the Insane. The work in New Hampshire was connected 
closely with the establishment of the Brattleboro Retreat. The 
slow growth of pu1)lic sentiment in the state is shown by the strug- 




X 



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Wi 



■•■*■- 



THE ERA OF AWAKENING 95 

gle in New Hampshire prior to the erection of the New Hampshire 
State Hospital. It took 1 1 years of continuous agitation before an 
institution was established at Concord. Even when established it 
was not a state institution, although it received state aid. Had it 
not been for the benefactions of benevolent friends it is doubtful 
whether it could have attained the degree of usefulness which 
afterwards came to it. In fact only within the past decade has the 
movement been concluded, which began in New Hampshire more 
than 70 years ago, to provide state care for the indigent insane. 

The Eastern Lunatic Asylum, now the Eastern State Hospital, 
Lexington, Ky., was opened as a state institution. May, 1824. This 
was the second state institution to be established in the United 
States, Williamsburg being the first. On July 25, 1828, Virginia 
provided a second state institution for the care of her insane, when 
the Western State Hospital was opened at Staunton. On Decem- 
ber 12, of the same year, the South Carolina Hospital at Columbia 
was opened, having been built by the state after a long and deter- 
mined effort on the part of two philanthropists who were not medi- 
cal men. The institution was designed for all classes of patients 
who paid their expenses or whose expenses were paid by the coun- 
ties. It was not a state institution as we understand it to-day. 

The three institutions just mentioned grew out of the success of 
the institution at Williamsburg, while the New York Hospital and 
McLean Hospital were largely the result of the good work inau- 
gurated in the Pennsylvania Hospital. 

The Friends' Asylum and the Hartford Retreat were both 
important factors in the erection and organization of the LTica 
State Hospital on broad lines. The commission charged with its 
construction and later with the duty of devising rules for its 
organization and management, although it had visited the insti- 
tutions for the insane then existing in this country, based its recom- 
mendations largely upon the experience of the Friends' Asylum 
and the Hartford Retreat. 

The organization of the Utica State Hospital had probably as 
much to do with the progress of the movement as any other single 
agency. Here we had an institution built by a state on an extensive 
and liberal scale, officered by meritorious appointment of officers, 
with definite laws for the admission and discharge of patients. 
The definite object of the institution was to take the insane out of 



96 INSTITUTIONAL CARE OF THE INSANE 

almshouses and to provide for them in a well ordered hospital. 
Here also for the first time under state charge was provided some 
accommodation for private patients of the semi-indigent class. 
The act under which the Utica Hospital was organized has been 
a model for similar institutions throughout the United States, and 
has undoubtedly proven an important agency in developing state 
care. 

The era of awakening came like a popular wave in various 
states and resulted in the establishment of institutions in many 
New England, Middle and Southern states. 

We now know that many of the views which were generally 
entertained and promulgated at that time were erroneous, and that 
mental disease was a much more serious constitutional disorder 
than any person realized. An excellent beginning, however, had 
been made and valuable work was accomplished in calling the 
attention of the different states to the needs of the insane. Several 
states had a single state institution, or one or more corporate 
hospitals for the care of acute and presumably curable cases of 
insanity. This provision, even in favored states where an insti- 
tution had been established, proved wholly inadequate. In a 
few years many patients had already passed through the institu- 
tion and, after receiving several months of treatment, had been 
returned as incurable to their friends, or to almhouses or houses 
of correction. The wave of enthusiasm which accompanied the 
original establishment of a hospital for the insane had spent itself 
in many states, and the insane, with the exception of comparatively 
few persons who remained under treatment in the newly estab- 
lished institutions, found themselves very much as they had been 
prior to hospital provision. Unquestionably the standard of care 
for the insane had been raised, and the hopes of friends and rela- 
tives had been stimulated to such a degree that they were no 
longer satisfied to have those in whom they were interested again 
neglected and abused. It is evident, however, that the country as 
a whole had not become aroused to the needs of the insane, that 
the majority of the states were destitute of special provision for 
their care, and that no state had provided sufificient institutions for 
their treatment. How long this condition might have continued 
cannot be predicted ; it is evident, however, that a'mighty influence 
in the person of Miss Dix, a woman of strength, of purpose, vigor 



THE ERA OF AWAKENING 97 

of mind and unusual activity, was an important factor in extending 
the work which had already hopefully begun in a half-dozen states. 
All concede that the labors of this remarkable woman contributed 
more to the general awakening of the country to the needs of the 
insane than all other agencies combined. Her labors during the 
next 40 years resulted in the establishment of nearly as many 
institutions for the insane in the United States and Canada, and 
also accomplished much in the same cause in England and upon 
the continent. It has been said that in the onward march of civili- 
zation the influence of men of ability and genius must always be 
regarded as controlling factors in its immediate progress. The 
influence of Miss Dix was unquestionably of this character, and 
without doubt her labors advanced the general care of the insane 
in America fully a quarter of a century. 



CHAPTER III 
PHILANTHROPIC WORK OF MISS DIX 



13 



I. 

DOROTHEA LYNDE DIX AND HER WORK.' 

All important crises in historical movements are associated with 
the lives and conduct of marked individuals ; persons who have 
advanced some original or discriminating conception as to duty 
or public policy, and who, through enthusiasm, strength of pur- 
pose and the force of personality, have initiated and conducted to 
a successful issue a notable departure in government, moral and 
religious convictions, social habits, or institutional methods. 

The history of insanity, in conformity with this universal law, 
has its conspicuous pioneers, its epoch-making masters, its heroes 
and heroines. In this connection many American specialists are 
entitled to more or less prominence. But from the standpoint of 
personal labors to promote practical reforms in public provision 
for the insane, the work of Dorothea L. Dix stands pre-eminent. 

Her surroundings in childhood were humble and she had a hard 
struggle to obtain an education, followed by a toilsome period 
spent in school-teaching. But in spite of these difficulties in her 
early life and of the semi-invalidism which, later on, hampered her 
physical activity, she achieved a national and even an international 
reputation as a practical philanthropist, her remarkable personal 
influence over public officials and governmental policies contribut- 
ing greatly to her success. In the 40 years of her public work she 
was instrumental in founding or enlarging more than 30 state 
institutions for the proper custody and right treatment of the 
insane,' becoming an acknowledged power in this respect not only 
throughout the United States, but in European countries as well. 
It is impossible to estimate how many men and women, suffering 
from mental disease, she extricated or preserved from public Jails 
and private pens, or how many others enjoyed release or exemption 
from galling chains and other cruel devices for restraint as a result 
of her humanitarian efforts. 

* The material for this chapter has been mainly gathered from a more 
elaborate paper now in preparation for separate publication by Dr. C. W. 
Page, of Hartford. 

* Tiffany, p. 361. 



I02 INSTITUTIONAL CARE OF THE INSANE 

Dorothea Lynde Dix was born April 2, 1802, at Hampton, Me., 
where her jxirents were temporarily located. Her father, Joseph 
Dix, was descended from good Puritan stock, which for genera- 
tions had maintained its stamina in New England. He himself, 
however, seems to have been lacking in mental balance and unable 
to maintain his wife and three children suitably. Having no 
established business occupation he repeatedly changed his resi- 
dence. His legal domicile was Worcester, Mass., but for short 
periods he endeavored to make a living in Maine, New Hampshire 
and Vermont. In reUgious matters his zeal outran his discretion, 
and at times his spirtual fervor led him to compose, publish and dis- 
tribute fanatical tracts. In her childish days the little Dorothea 
was often called upon to paste and stitch these unprofitable leaflets. 
The mother evidently lacked force of character sufficient to coun- 
terbalance her husband's weak judgment, or even to command the 
respect of her eldest child. 

Under such family circumstances, deprived of the care and 
attention, the material comforts and the agreeable associations 
requisite to satisfy normal childish longings, the bright, sensitive, 
proud-spirited Dorothea suffered grievously. In after years she 
once made the pathetic avowal, " I never knew childhood." 

When she was 12 years of age, her native good sense and 
awakening ambition asserted themselves. She refused to con- 
tribute further aid to her father's tract-making schemes and 
repaired to her grandmother's house in Boston, where she was 
sure of a welcome and had the advantages of a superior home, 
good schools, association with cultured people and a loving 
intimacy with her grandmother, a dignilied and circumspect, but 
kind and judicious woman, so commonly found among Puritan 
families in New England. Her grandfather, a physician and 
chemist, was a well-known man, long remembered for his strong 
character and unique personality. He was industrious, thrifty, 
fertile in resource and scrupulously honest. Endowed with clear, 
far-sighted judgment, unusual energy and conspicuous courage, 
he often originated new and startling propositions in business, 
both public and private. In fact, his confidence in his own wisdom 
and conscientious intentions made him at times somewhat aggres- 
sive in matters of public interest. Dorothea seems to have inherited 
many of his ])rominent traits. Unfortunately his death, when she 



DOROTHEA LVNDE DIX AND HER WORK IO3 

was seven years of age, deprived her of his aflfection and counsel 
in her struggle for a position of independence and influence. 

Dorothea, after two years with her grandmother in Boston, 
occupied in diligent study, returned to Worcester to open a school 
for children. This first school was a moderate success. She was 
a faithful and earnest teacher, but an exacting disciplinarian. The 
school proved to be short-lived, and was discontinued after a few 
months. With added experience and a better comprehension of 
her own educational limitations, Dorothea determined to fit herself 
to teach older pupils and to give higher courses of instruction. 
With this intention she returned to Boston, where she studied 
industriously and read much in general literature, until in 182 1, at 
the age of 19 years, she considered herself competent to teach 
young ladies and opened a day school in Boston. 

She not only wished to gain personal independence for herself, 
but also to support and educate her two brothers. The small 
house in which the school was opened soon became overcrowded 
and was exchanged for her grandmother's residence, known as 
the " Dix Mansion." The high reputation which the school 
acquired attracted pupils from prominent families in Boston and 
elsewhere throughout Xew England. \\'ith the rapid develop- 
ment of her school, Aliss Dix gradually assumed many arduous 
duties : she managed the household, taught in the day and board- 
ing school, nursed her aged grandmother, and finally from a 
lively sense of duty to the poor opened a charity school. These 
labors proved too much for her strength, and at the end of six 
years her health failed. In 1827, when the Dix School was sus- 
pended because of her disability, she entered the family of Wil- 
liam Ellery Channing, D. D., as governess and spent several suc- 
cessive summers at Portsmouth, R. I. 

In 1830 she went to the West Indies with the Channings, and 
in this benignant tropical climate, surrounded by new and luxuri- 
ant vegetation, entertained by unfamiliar customs, and fascinated 
by the novelties of a new world, she found complete mental relaxa- 
tion. \'arious branches of natural history attracted her attention, 
everything new in her experience receiving searching investiga- 
tion and being catalogued in her memory, if not in her voluminous 
note-books. Geological formations, landscapes, flora, fauna, har- 
bors, shores and ocean-currents, in short, all the novel phenomena 



I04 INSTITUTIONAL CARE OF THE INSANE 

within her conscious horizon, engaged her critical interest now 
that she had time and opportunity to indulge her natural thirst 
for information. The keen discrimination shown in her reports 
and the value of the specimens which she collected elicited letters 
of appreciation from Audubon and Silliman. 

At the end of her sojourn at St. Croix, Miss Dix found herself 
refreshed both in mind and body by the tropical climate, together 
with a complete relief from responsibility and hard work. In 183 1 
she returned to Boston and reopened the " Dix Mansion Day and 
Boarding School," an enterprise which embodied her most cher- 
ished ideas. The school was a great success and soon became 
known as a model. Miss Dix's riper age, fuller knowledge and 
wider experience made her an authority on education, W'hile the 
ardor which vitalized all her projects made the school so popular 
that many pupils had to be rejected. The curriculum included 
little besides the common English branches of study but the drill 
in deportment and the fundamentals of a good English education 
was thorough and correct. For five years Miss Dix labored un- 
sparingly in her school, but her undermined constitution could not 
support the strain involved, and in 1836 her health again failed. 
Her nervous system became exhausted, she suffered from pleuritic 
pains, and had frequent haemorrhages. 

In these five years she had established an enviable reputation as 
a teacher; she had housed, clothed and educated her dependent 
brothers, and she had accumulated a modest competence for future 
self-support, but all this had been accomplished at the cost of 
physical health. 

The best medical opinion which Miss Dix could obtain recom- 
mended a voyage to Europe and a temporary residence in the south 
of France or Italy. She acted upon this advice, and, in the com- 
pany of a friend, sailed from New York in April, 1836. When 
England was reached, however, she was too weak to travel by 
rail. Some English friends of Dr. Channing found her on a sick- 
bed in a Liverpool hotel and insisted upon removing her to their 
country home, a few miles from the city. In this way she became 
an inmate of the hospitable dwelling, where she remained for 14 
months a welcome guest and was most tenderly cared for, much 
of the time as an invalid or at best as a convalescent. 



DOROTHEA LYNDE DIX AND HER WORK IO5 

Miss Dix's mother and grandmother both died during her stay 
in England, and in 1837 business interests necessitated her return 
to America. Her health, though improved, was not firmly re- 
established, but as her brothers were successfully established in 
business, and the funds she had accumulated in teaching, increased 
by an inheritance from her grandmother's estate, yielded an income 
sufficient for her support, she was no longer obliged to keep up 
her school. 

About this time she became interested in prisons and prison 
reform and in 1841, when 39 years of age, she entered upon the 
career which was to make her known to the world as a practical 
philanthropist. Never did the " massive gates of circumstances 
turn upon a smaller hinge." Some theological students in Cam- 
bridge had undertaken to teach a Sunday school in the House of 
Correction. One of them, J. T. G. Nichols, hesitated to undertake 
a class of 20 female prisoners and, on confessing his trepidation to 
his mother, was urged to consult Aliss Dix, who quickly solved the 
problem by taking upon herself the task of instructing the women 
convicts.^ Through this work she acquired an inside knowledge of 
conditions in the institution. She discovered overcrowding, un- 
cleanliness and the herding together of the innocent with the guilty 
and the sane with the insane, a condition of things which at that 
time characterized the prisons and almshouses not alone of Massa- 
chusetts, but throughout the world. 

Her first step was an effort for the relief of a few insane per- 
sons confined in bitterly cold rooms. She urged the official in 
charge of them to provide sufficient heat, but without success ; on 
which she immediately applied to the judge, then holding court 
in the adjacent court house, and obtained an order requiring the 
keeper of the prison to heat the prisoners' quarters as she sug- 
gested. 

Having reason to suppose that the insane in other jails and 
almshouses were improperly, if not brutally, treated, she began a 
personal investigation of all such institutions. The discoveries she 
made were shocking. In her school-teaching days of autocracy, 
justice with mercy was her guiding principle of action, and prompt 
action was her rule. This deeply grounded sense of the majesty 
of the moral law had not grown dim with age and experience, but 

' Tiffany, p. "]},. 



I06 INSTITUTIONAL CARE OF THE INSANE 

intimate association with cultured people in the North and South 
and in England had somewhat softened her self-assertion, and 
she was now able to conceal her indignation until she could com- 
mand the fitting occasion for reproof. There had never been a 
time when she would not have braved martyrdom if moved by 
the sense of righteous wrath, but she had now become mistress of 
tact and self-restraint, to be exercised when the object which she 
had in view demanded them. Impetuous as she was, even in her 
mature years, she always took the precaution to provide suf- 
ficient ammunition before she opened her batteries upon her 
opponents. In this, as in all her subsequent campaigns for the 
insane, she began by securing all the important facts, to which end 
she canvassed the whole state, carefully inspecting jails and alms- 
houses and giving close attention to obscure cells and dark corners 
in order that no distressing case might escape her. She wrote 
accurate descriptions of everything disclosed by her search that 
deserved criticism, and arranged all this information in a system- 
atic scheme. 

In her first great public contest, she fortified her own con- 
victions by consultations with a number of intimate friends; a 
group of broad-minded, public-spirited citizens, such as Rev. Dr. 
W. E. Channing, Charles Sumner, Horace Mann, Rev. Robert C. 
Waterson, Drs. S. G. Howe, Luther V. Bell and John S. Butler. 

Her fight for the insane in Massachusetts reached its climax 
when she presented her " Memorial " to the State Legislature. It 
concludes as follows : " Men of Massachusetts, I beg, I implore, 
I demand, pity and protection for those of my suffering, outraged 
sex. Fathers, husbands, brothers, I supplicate you for this boon — 
but what do I say ? I dishonor you, divest you at once of Chris- 
tianity and humanity ; does this appeal imply distrust? Here you 
will put away the cold, calculating spirit of selfishness and self- 
seeking, lay ofif the armor of local strife and political opposition; 
here and now, for once, forgetful of the earthly and perishable, 
come up to these halls and consecrate them with one heart and one 
mind to the work of righteousness and just judgment. Gentlemen, 
I commit to you this sacred cause. Your action upon this subject 
will affect the present and future conditions of hundreds and thou- 
sands. In this legislation, as in all things, may you exercise that 
wisdom which is the breath of the ]:»ower of God." This indict- 



DOROTHEA LVNDE DIX AND HER WORK III 

to shape public opinion in such a manner as to secure the favorable 
support of the politicians. For nearly two years Miss Dix worked 
upon preliminary details. In 1845 her '' Memorial " was presented 
to the legislature by Mr. Dodd, who also submitted a resolution 
proposing immediate action by the state to establish a public insti- 
tution for the insane.' Subsequently the joint committee having 
in charge the hospital bill reported in favor of its adoption, declar- 
ing that " Miss Dix's Memorial presented the whole subject in so 
lucid a manner as to supersede the necessity for further remarks " 
as to the necessity for immediate action. The report concluded 
with an appeal for united support, acknowledging state delin- 
quency and the reasonableness of the proposition. It admitted that 
patriotic, philanthropic, and Christian considerations demanded a 
state hospital for the insane ; that New Jersey was " behind her 
sister states, behind the spirit of the times and the movements of 
the age," in withholding public provision for the better care of the 
insane; that the institution proposed in the bill would confer bless- 
ings to be felt immediately and for all time to come ; that it would 
in short " reflect more lasting honor on the state and tell more for 
human happiness than all the legislation for the past century.'" 

Such a report would seem to promise certain success, yet the 
passage of this resolution was the occasion which, of all Miss 
Dix's reform movements, taxed her faculties most severely and 
witnessed her greatest triumph over difificulties. While legislation 
upon her hospital bill was pending, her energies were subjected to 
the most exhausting demands. Difficult problems would require 
comprehensive solutions, perplexing situations would develop with 
unexpected suddenness, or the question whether hostile movements 
should be placated or defied would call for immediate shrewd 
decision. Under these conditions, the exercise of political as well 
as common sense was essential, while familiarity with state afifairs 
in general, a complete acquaintance with the facts involved, an 
accurate knowledge of human nature and a quick perception of 
character were imperative. Miss Dix endeavored to become 
acquainted with every member of the legislature, in order that she 
might fathom each man's mental endowment and moral standards, 
thus discerning his natural impulses and constraining ideals, 
besides gauging his sense of responsibility. With the knowledge 

'Tiffany, p. 112. ''Tiffany, p. 113. 



112 IXSTITUTIONAL CARE OF THE INSANE 

thus obtained, she was able to correct the mistaken views of these 
men and to instruct and convince them in favor of expensive 
humane institutions, as well as to meet all the conditions that arose, 
but to accomplish ends called into action all her sense and all her 
intelligence, in fact every resource controlled by her great heart 
or within the range of her fertile mind. While thus engaged she 
wisely avoided entering legislative halls, and courtesy invariably 
assigned for her temporary occupation some adjacent room, 
library, alcove or quiet corner. Thither members of the legislature 
would come, some from inclination, others in response to an invi- 
tation from Miss Dix or from an ally, with divers objects in view ; 
it might be to report progress, or to disclose fresh obstacles, to 
obtain information, or to argue certain points at issue, and it is sur- 
prising how completely philanthropists, political leaders and public 
officials tacitly acknowledged her supremacy in such affairs. In 
the evenings she often received such visitors, especially the recal- 
citrant contingent, in boarding-house parlors, and with these she 
would explain, expostulate and entreat, in behalf of the helpless 
insane, as though her own life were the impending issue. In a 
letter to a friend, written while conducting one of her legislative 
sieges, she disclosed how keenly she felt the magnitude of the job. 
" I must have sympathy," she wrote to Mrs. Hart, " just now I 
need calmness. I am exhausted under this perpetual effort and 
exercise of fortitude. At Trenton thus far all is prosperous, but 
you cannot imagine the labor of conversing and convincing. Some 
evenings I had at once 20 gentlemen for three hours' steady 
conversation." 

The method by which she " convinced " members of the legisla- 
ture will be understood from an incident which she describes in 
the same letter. One evening " a rough country member," who 
had proclaimed in public that " the wants of the insane in New 
Jersey were all humbug," came to her usual conference to convince 
her that his antagonistic views were substantially correct. " After 
listening an hour and a half," she says, " with wonderful patience 
to my details and to principles of treatment, he suddenly moved 
into the middle of the room and said, ' I bid you good night. For 
my part I do not want to hear anything more. You've conquered 
me out and out. I am convinced.' 

' Tiffany, p. 115. 



DOROTHEA LVNDl-: DIX AND HER WORK IO7 

ment of the state practices was drastic, but, as usual with her 
onslaughts, it led to a proposition for immediate remedy, namely, 
the enlargement of the Worcester State Hospital. 

Her friend. Dr. S. G. Howe, then a member of the House of 
Representatives, presented her petition and vouched for the truth 
of all the statements contained in it ; nevertheless, it aroused a 
storm of angry protests. Public officials, interested politicians 
and their newspaper organs, all united to discredit the severe 
arraignment, alleging that Miss Dix had uttered false and libelous 
statements. She calmly replied that she had simply stated matters 
of fact which she was ready to substantiate. And here she took 
her especial attitude as a reformer, an attitude she always main- 
tained in her work for the insane. She declared, with emphasis, 
that she was not actuated by vindictiveness or personal feelings 
towards the jailers and keepers, who were inflicting such harsh 
treatment upon the innocent and helpless, for she believed the 
horrible conditions surrounding the insane, which then existed 
almost universally, were due to an antiquated, ignorant and callous 
system of public policy based upon theories and practice which 
must be revolutionized out of respect to Christianity and advanc- 
ing civilization. Public opinion raged about her, but the best senti- 
ment of the community immediately rallied to her support, and 
the shrewder political magnates, forecasting the outcome, soon 
acquiesced in the impeachment. 

As the indefensible facts gradually sank into the consciousness 
of the people, a wave of indignation at the tolerance of such 
wrongs spread through the community and so impressed the mem- 
bers of the legislature that they ultimately adopted the hospital 
bill by a large majority. 

This great victory, the reward of singular ability and marvelous 
management, did not increase her self-complacency, but seemed 
rather to soften her. She came to a realizing sense of her personal 
power, but her mind was engrossed in the fact that there remained, 
in other states, throughout the land, thousands of insane persons 
whose keen sufiferings would in no degree be assuaged by her 
signal success in Massachusetts. 

She comprehended the serious conditions of the insane through- 
out the country, and to her understanding had been revealed the 
best method to arouse and energize indifferent sentiments upon 



I08 INSTITUTIONAL CARE OF THE INSANE 

this neglected subject. She anticipated the Herculean struggle 
before her, and fully realized the bitter opposition she was destined 
to encounter, and the physical and mental exhaustion which might 
ensue ; but such formidable presentiments of the consequences 
could not block her determination, and she consecrated the balance 
of her life without reserve to the cause of the wretched insane. 

Convinced that it was the imperative duty of each state to pro- 
vide more hospitals, or enlarge hospitals, for the insane, Miss Dix 
undertook to persuade or compel the various commonwealths to 
accept her ideals and adopt her suggestions. What others had 
evaded, she resolutely confronted, believing that where she could 
secure the necessary legislation, or obtain the requisite funds for 
such institutions, the desired solution of this burning question 
would naturally follow. Therefore, she restricted her efforts to 
the main object in view, relying upon others to work out the details 
of construction and internal management, and in all her subsequent 
labors she adhered in the main to this program. 

Thus, having obtained her immediate purpose in Massachusetts, 
she turned her attention to Rhode Island, where conditions affect- 
ing the insane were no better than those which the State of Massa- 
chusetts had just repudiated. 

Here again she conducted a thorough search in each city and 
township, laboriously recording the many discreditable instances 
of abuse and neglect she discovered, protesting to state officials, 
and seeking the co-operation of local philanthropists, as she un- 
earthed case after case of barbarous treatment of unfortunate 
imbeciles and maniacs. Enlisting the aid of the press she caused 
to be published in the Providence Journal, April lo, 1844, the 
pathetic details of one pitiable case in particular. Other exciting 
articles and editorial comments followed, while at the same time 
Miss Dix was pleading with influential citizens to assist in arous- 
ing public abhorrence. Eventually her grim " Memorial "' to the 
legislature was delivered. Her method of agitation, as was in- 
tended, produced a state of excited, almost violent, opposition 
against long existing conditions which most citizens, however 
kindly disposed, regarded as irremediable, though they knew them 
to be wrong. But fortunately for the reforms which Miss Dix 
undertook, she possessed unusual constructive genius. Although 
decided and rapid progress was being made, the development of 



DOROTHEA LYNDE DIX AND HER WORK IO9 

the grand action which she had staged moved too slowly to suit her 
impetuous nature. Scanning a list of prominent business men, 
financially able to assist her in precipitating a denouement, she 
selected the name of Cyrus Butler. Xow, Mr. Butler was wealthy, 
and his established reputation was notable, in respect of industry, 
frugality and good dividend-paying investments ; but he was prob- 
ably the last rich man in the state that well-posted charity agents 
would solicit for a large benevolent donation. Notwithstanding 
the hopeless predictions of her associates as to the outcome, she 
walked into Mr. Butler's office without the formality of an intro- 
duction. According to TiiTany's version of the interview which 
followed, Mr. Butler endeavored for a time to limit the range of 
conversation to general topics, the weather, etc. " Preserving her 
temper and self-control Miss Dix pleasantly adjusted herself to 
the humor of the scene until, feeling that the thing had gone far 
enough, she arose with commanding dignity and said, ' Mr. Butler, 
I wish you to hear what I have to say ; I want to bring before you 
certain facts involving terrible suffering to your fellow-citizens all 
around you ; sufferings which you can relieve. My duty will end 
when I have done this, and with you then will rest the responsi- 
bility.' " ^ Howsoever this interview terminated, it is believed in 
Providence that Mr. Butler had discussed this subject with other 
parties before Miss Dix saw him, and that he deliberated some time 
before he decided to contribute $40,000 to ensure the erection of 
Butler Hospital for the Insane. To found this institution Nicho- 
las Brown, a merchant and philanthropist of Providence, had 
already bequeathed by will $30,000, and in view of the larger gift 
of Mr. Butler made during his life the first incorporated mental 
hospital in Rhode Island was given the name of the latter. Miss 
Dix's propaganda helped materially to inform and vitalize public 
sentiment regarding the insane in Rhode Island, and, being satis- 
fied with the results, she selected New Jersey as the next field for 
her humane operations. 

The lethargy of public sentiment in New Jersey, respecting 
insanity and its proper treatment, may be inferred from the fact 
that no institution whatever for the especial custody and care of 
the insane had been provided by the state. Miss Dix began an 
immediate personal investigation of the many jails and alms- 

* Tiffany, p. loi. 



no INSTITUTIONAL CARE OF THE INSANE 

houses. She recorded the details of all pertinent cases, and 
before her real purpose had become a matter of common informa- 
tion she had all the relevant facts and figures upon which to base 
criticisms, arguments and conclusions. This personal knowledge 
she wove into her New Jersey " Memorial," which was a brilliant 
summary of her observations, as well as a public impeachment like 
that which she issued in New England, though more moderate in 
tone and amiable in spirit. It is true that the insane in New Jersey 
were suffering under neglect and unsuitable surroundings, but in 
this indictment she made the rewards for benevolence towards 
them a central thought. The great benefits which might be con- 
ferred upon the afflicted insane with their responding gratitude 
were charmingly pictured. The softened style of this presentment 
was probably due to a politic consideration of those whom she was 
addressing. She had visited all sections of the state, had conferred 
with many of its leading citizens and had shrewdly sounded public 
sentiment, noting the bent of prevailing influences. She seemed 
to possess an instinctive faculty for discovering potential springs 
of action in the minds of others, with an alert capacity for adjust- 
ing her mode of attack or supplication, to accord with varying 
opinions and sentiments, as they predominated with individuals 
and communities. In the course of her philanthropic career she 
encountered thousands of persons, representing all grades of 
mental ability and all ranks of society, and but few individuals out 
of these multitudes were wholly indifferent to her adroit address, 
her fitly chosen words and the charm of her personality. 

Before Miss Dix's advent many of the best people in New Jersey 
had become satisfied that public provision for the insane in their 
state was a pressing necessity, but these enlightened persons were 
outnumbered by a voting majority opposed to liberal state appro- 
priations. Miss Dix's voluntary assistance in provoking discussion 
and educating public intelligence on this subject was, therefore, 
appreciated and welcomed by the better informed of the com- 
munity. Under such salutary conditions, censorious statements 
would have been uncalled-for aggressions. The sympathetic and 
helpful friends whom she met (especially among the Quakers) 
strengthened her courage and so qualified the situation with which 
she had to deal, that she wisely modified her original style of 
attack. Nevertheless, it required vigorous and prolonged effort 



Her methods have been described sufficiently to show her ver- 
satiHty in meeting both the ordinary and the unusual vicissitudes 
of a legislative campaign. In this particular instance she per- 
severed with faith until her self-appointed mission in New Jersey 
was crowned with victory. Upon March 25, 1845, legislation 
reached its final stage and the Senate unanimously passed the re- 
engrossed bill for the New Jersey Lunatic Asylum. 

In Massachusetts and Rhode Island iMiss Dix's aim had been to 
secure the enlargement of existing provision, but in New Jersey 
her design had no connection with antecedent institutions, and her 
efforts were directed to the establishment of a new and independ- 
ent state hospital. Of her many successes in life probably none 
gave her such immediate and permanent gratification as the pas- 
sage of this legislative enactment. She watched the beginning and 
the development of this magnificent charity with satisfaction and 
pride, and she often referred to this hospital as her " first-born 
child." She loved to visit and revisit this monument to her early 
struggle for the cause of humanity, especially when suffering from 
physical exhaustion and weariness of spirit as the consequence of 
arduous labor in other fields of duty. And when, by reason of her 
advancing years, infirmities incident to her age necessitated inac- 
tion, she joyfully accepted an official invitation to spend the remain- 
der of her days within its hospitable shelter. 

Miss Dix possessed extraordinary business capacity. However 
intent she might be on accomplishing some large purpose in a given 
state, she was, as a rule, engaged at the time in preparing for and 
developing movements of a like character in several other states. 
And she was able to do this without confusing matters of fact, 
mistaking the identity of individuals, or sacrificing interest in the 
details of each subject. 

While absorbed in her New Jersey undertaking, Miss Dix had 
found time to journey extensively, always collecting first-hand 
information as to the conditions and the inmates of jails and alms- 
houses. On one of these occasions she made a zealous quest in 
Pennsylvania, which she conducted with such efficiency that a bill 
founding an entirely new hospital for the insane passed the legis- 
lature at Harrisburg about the time the New Jersey state hospital 
bill passed at Trenton. 



DOROTHEA LYNDE DIX AND HER WORK II3 

Her methods have been described sufficiently to show her ver- 
satility in meeting both the ordinary and the unusual vicissitudes 
of a legislative campaign. In this particular instance she per- 
severed with faith until her self-appointed mission in Xew Jersey 
was crowned with victory. Upon March 25, 1845, legislation 
reached its final stage and the Senate unanimously passed the re- 
engrossed bill for the New Jersey Lunatic Asylum. 

In Massachusetts and Rhode Island Miss Dix's aim had been to 
secure the enlargement of existing provision, but in New Jersey 
her design had no connection with antecedent institutions, and her 
efforts were directed to the establishment of a new and independ- 
ent state hospital. Of her many successes in life probably none 
gave her such immediate and permanent gratification as the pas- 
sage of this legislative enactment. She watched the beginning and 
the development of this magnificent charity with satisfaction and 
pride, and she often referred to this hospital as her " first-born 
child."' She loved to visit and revisit this monument to her early 
struggle for the cause of humanity, especially when suffering from 
physical exhaustion and weariness of spirit as the consequence of 
arduous labor in other fields of duty. And when, by reason of her 
advancing years, infirmities incident to her age necessitated inac- 
tion, she joyfully accepted an official invitation to spend the remain- 
der of her days within its hospitable shelter. 

Miss Dix possessed extraordinary business capacity. However 
intent she might be on accomplishing some large purpose in a given 
state, she was, as a rule, engaged at the time in preparing for and 
developing movements of a like character in several other states. 
And she was able to do this without confusing matters of fact, 
mistaking the identity of individuals, or sacrificing interest in the 
details of each subject. 

While absorbed in her New Jersey undertaking. Miss Dix had 
found time to journey extensively, always collecting first-hand 
information as to the conditions and the inmates of jails and alms- 
houses. On one of these occasions she made a zealous quest in 
Pennsylvania, w^hich she conducted with such efficiency that a bill 
founding an entirely new hospital for the insane passed the legis- 
lature at Harrisburg about the time the New Jersey state hospital 
bill passed at Trenton. 



114 INSTITUTIONAL CARE OF THE INSANE 

Procrastination was impossible with Miss Dix and five days 
after the Trenton Hospital was legally established, she was on 
board a steamer, lying-to in a storm, near Charleston, S. C. While 
thus detained she wrote a letter in which she outlined her 
immediate plans. " I design using the spring and summer chiefly 
in examining jails and poorhouses in Indiana and Illinois. Having 
successfully completed my mission in Kentucky, I learned that 
traveling in the states referred to would be difficult, if not impos- 
sible, for some weeks to come, on account of rains and mud. This 
decided me to go down the Mississippi to examine the prisons and 
hospitals of New Orleans and return to sec the state prison of 
Louisiana at Baton Rouge, of Mississippi at Jackson, of Arkansas 
at Little Rock, of Missouri at Jefferson and of Illinois at Alton. I 
took the resolution, being so far on the way, of seeing the state 
institutions of Georgia, Alabama and South Carolina. Though this 
had proved exceedingly fatiguing I rejoice that I have carried out 
my purpose." ' 

The prodigious amount of hard work that Miss Dix was able to 
perform amazed her friends more especially as her physical condi- 
tion was precarious. All through her middle life she had recurring 
haemorrhages, and after her journeys and labors in the Southern 
states she was frequently prostrated by malarial fever. She had 
few confidants, and even those so favored were able to trace her 
activities only in part. About the time the Trenton and Harrisburg 
Legislatures passed her hos])ital bills she indulged to some extent 
in personal reminiscence, when writing to her old friend, Mrs. 
Rathbone, of Liverpool. " I have traveled," she wrote, " more 
than 10,000 miles in the last three years. Have visited 18 peniten- 
tiaries, 300 county jails and houses of correction, more than 500 
almshouses and other institutions, besides hospitals and houses of 
refuge. I have been so happy as to promote and secure the estab- 
lishment of six hospitals for the insane, several county poorhouses 
and several jails on a reform plan."" 

Each successive triumph in her philanthropic work increased 
public confidence, as well as her own faith in her ability to secure 
favorable legislation for humane purposes. She was constitution- 
ally resolute, and with successful experience in arousing public 

'Tiffany, p. 123. "Tiffany, p. 132. 



DOROTHEA LVNDE DIX AND HER WORK IIS 

sentiment and promoting appropriation bills, she came to possess a 
greater degree of assurance ; relying at all times upon the support 
of an overruling Providence in a just cause, she feared no combina- 
tion of circumstances. Her original methods of dealing with men 
and measures were incomprehensible to the ordinary politician. 
Her strategic arts baffled her opponents and seemed at times to 
acquire magical potency. 

At Raleigh, N. C, she was coolly informed that the ruling party 
had resolved that no bill involving large expense should pass the 
legislature. Learning this fact, Miss Dix requested the leading 
Democratic members to meet her and when they were assembled, 
she thus addressed them : " Here is the document I have prepared 
for your assembly, I desire you, sir, to present it" ; handing it to a 
man very popular in his party, "and you gentlemen," turning to 
the astonished delegation, " I expect will sustain the motion this 
gentleman will make to print the same." The papers were pre- 
sented to the legislature, as suggested, and a motion to print 12 
extra copies for each member was unanimously passed. Within 
six weeks a bill to establish the Raleigh Insane Asylum passed the 
assembly with only 10 opposing votes. 

As her successful generalship in securing legislation for the 
insane extended, her services for such projects were more and 
more in demand. Often leading citizens, or an ambitious majority 
in some state, despairing because of inability to carry measures for 
their own insane, called upon her for assistance. Again, public 
officials, appreciating a necessity for new or enlarged institutions, 
yet dreading responsibility for suggesting the requisite appro- 
priations, preferred to mask their designs by her prominence, and 
to follow her leadership. Yielding to such requests, or following 
her own ideas of duty and judgment, she toured through this 
country again and again, securing in most states improved con- 
ditions, if not radical changes, for the better for the helpless insane, 
and leaving along the way more than a score of important public 
institutions, each of which is a conspicuous monument to her 
extraordinary ability and her devotion to the cause of humanity. 

During the winter she would confine her engagements to the 
Southern states, returning North as the spring advanced, and con- 
tinuing her unselfish work in Canada through the summer. There 
were, of course, some interruptions to this general program. In 



Il6 IXSTITUTIOXAL CARE OF THE INSANE 

1854 she left the country and remained abroad for two years ; and 
again, while the Civil \\'ar lasted, she was busy with general hos- 
pital work for the government. 

The most ambitious scheme propounded by ]\Iiss Dix contem- 
plated a public land grant for charitable purposes. Her first 
" Memorial," presented to Congress in 1848, called for a " grant of 
5,000,000 acres of the public domain, the proceeds of the sale of 
which were to be set apart as a perpetual fund for the care of the 
indigent insane." This " National Memorial " was compiled from 
the state " Memorials " which had already done efficient duty, 
each in its own state, in connection with local legislation. It 
rehearsed the most flagrant instances of neglect and abuse of the 
insane as discovered by her in all the states. Pathetic, harrowing, 
almost incredible details were rearranged for efifect upon Con- 
gressmen and the reading public, in terms so explicit, so positive 
and so unanswerable, that nothing short of consternation could 
result from their perusal. It opened as follows : " Present hospital 
provision, excluding institutions not considered remedial, relieves 
less than 3700 patients. Where are the remainder and in what 
condition? More than 18,000 are unsuitably placed in private 
dwellings, in jails, in poorhouses, and often most wretched habita- 
tions. I have myself seen more than 9000 idiots, epileptics and 
insane in these United States, destitute of appropriate care and 
protection ; and of this vast and miserable company, sought out in 
jails, in poorhouses and in private dwellings, there have been hun- 
dreds, nay — rather thousands — bound with galling chains, bowed 
beneath fetters and heavy iron balls attached to drag-chains, lacer- 
ated with ropes, scourged with rods and terrified beneath storms 
of execration and cruel blows ; now subject to jibes and scorn and 
torturing tricks ; now abandoned to the most loathsome necessities, 
or subject to the most outrageous violations. These are strong 
terms, but language fails to convey the astonishing truths. I pro- 
ceed to verify this assertion, commencing with the State of Maine." 
Each state in turn was accused of permitting all degrees of inhu- 
manity towards its defenseless insane, and every charge in the 
declaration was substantiated by the history of cases, with the 
locality where found, etc., the names of the individuals involved 
alone being omitted. In conclusion, she assumed that the insane 
were wards of the nation, and reminded Congress that precedents 



DOROTHEA LYNDE DIX AND HER WORK II7 

for granting her request were established when the United States 
Government donated portions of such common property to certain 
states for educational purposes and to schools for the deaf and 
dumb. Her " Memorial " was referred to a special committee and 
5000 copies were ordered printed. A special committee room in the 
Capitol was set apart for her use by the courtesy of Congress ; and 
when that body was in session she could be found at her post there, 
working with all her skill and power to secure the support of 
Representatives and Senators. This broad scheme of national 
charity was, as a rule, well received. Prominent members of Con- 
gress treated her with such respect and her proposed land grant 
with so much consideration, that she was encouraged to expect 
early and favorable action. Then, to strengthen her position and 
to show herself wholly consistent, she presented a second petition, 
praying for 2,000,000 acres more of the public land, for the bene- 
fit of the blind and deaf and dumb. While Miss Dix declared that 
she was never sanguine and confident regarding legislation, " only 
when a bill had passed into an act and is sealed by governor or 
president," a letter written by her on July 21, 1845, rings loud with 
assurance. She states the fact that the committee named by her 
had been appointed and that when her favorite chairman could not 
serve because of sickness, his official position had passed into the 
hands of one of her new partisans. " I really think," she wrote, " if 
Congress does not suddenly adjourn, I shall pass the bills, one ask- 
ing for 5,000,000 acres of public surveyed land for the curable and 
incurable insane ; and the other praying for 2,000,000 acres for the 
blind and the deaf and the dumb." Although, perhaps, warranted 
in believing that a majority of both houses favored her bills she 
could not obtain action, definite consideration being again and 
again deferred. 

Before long an agrarian agitation started in the Eastern states 
and spread rapidly through the whole country. This popular 
expression of public policy induced the wary politicians to pro- 
crastinate with the land bills. Finally President Polk announced 
that he would " veto all and every land bill which did not make 
provisional payment to the general government." 

Miss Dix noted every political move and estimated its force. In 
this case six months' observations and hard work convinced her 
that hasty action would be inexpedient. 'T think the bills may be 



Il8 INSTITUTIONAL CARE OF THE INSANE 

deferred till the next session," she wrote to her brother, January 
30, 1849. She hopefully suggested that President Polk's objec- 
tions could be overcome by paying the government " a small 
premium upon each acre sold." " Fortunately," she adds, " I am 
on good terms with Mrs. Polk and the President." When Con- 
gress met in 1850 Miss Dix put in a revised bill, in which she had 
nearly doubled the amount of public land wanted for her benev- 
olent purposes. She now saw need for 12,225,000 acres of the 
public domain, of which grant 10,000,000 should inure to the bene- 
fit of the insane, and 2,225,000 to that of the blind and the deaf 
and dumb. 

Again her " Memorial " was well received by members of the 
House and was sent to a special committee. The press, in general, 
approved her consolidated bill. It was endorsed by the best leaders 
of public sentiment, while philanthropists and interested asso- 
ciations gave it their hearty support. The superintendents of 
American institutions for the insane voted : " That this association 
regards with deep interest the progress of the magnificent project 
which has been and continues to be urged by Miss Dix on the con- 
sideration of Congress, proposing the grant of a portion of the 
public domain by the Federal Congress, the proceeds of which are 
to be devoted to the endowment of public charities throughout the 
country, and that it meets with our unqualified sanction. (Signed) 
Thomas S. Kirkbride, secretary." Late in the summer of 1850 her 
bill passed the House of Representatives. She was kept in a state 
of mental tension for some time with hopes that the Senate would 
concur, and with fears that it might not ; ultimately the bill was 
deferred until the next session. At the winter session Miss Dix 
resumed her eflforts to get the bill through, and was well pleased 
when it passed the Senate on February 2, 1851. The bill had now 
passed both Houses, but final action in each had not been reached 
in the same session, consequently the bill had to go back to the 
House of Representatives for re-approval. But when it was sent 
back, parliamentary tactics were employed to avoid a decision. A 
rigid enforcement of the rules serves such a purpose at times. 
Twice the rules were suspended to take up the bill, but each time 
opponents, by adroit management, induced the House to proceed 
to business. By such methods, in spite of its many friends, the 
bill was again forced to lapse. 



DOROTHEA LYNDE DIX AND HER WORK II9 

Non-propitious political skies led Miss Dix to wait nearly two 
years before she again appealed to Congress in 1852 for a land 
grant ; and then she made but a feeble attempt to push its consider- 
ation. But when the session of 1854 opened, the prospects of the 
bill seemed brighter, as public discussion of the land grant scheme 
had subsided, and Franklin Pierce had become President, so it was 
again brought forward. 

Meantime Miss Dix had worked hard in many states, and had 
won several glorious issues for the insane on Southern fields. She 
had good reason to expect that her rapidly growing national repu- 
tation had conferred upon her additional power of personal 
influence. Her native courage was undimmed and she was deter- 
mined to push the land grant through Congress, if possible. She 
was never more resolute, never more buoyant in spirits and never 
better prepared for such an undertaking. Men who commanded 
. great respect in both houses assisted her in advancing the measure 
and it passed the Senate by a large majority in March, 1854. Five 
months later it passed the House with 98 votes in its favor, and 
84 against it. 

Her biographer claims that this " Congressional achievement of 
Dorothea L. Dix will always stand out among the memorable 
moral triumphs of history." She received a flood of congratula- 
tions from the eminently good and wise, representing all sections 
of the country. Naturally she was elated and greatly encouraged, 
yet she was somewhat anxious while waiting for the signature of 
the President, which she fully expected would be attached to the 
bill. In this, however, she was doomed to disappointment. After 
six years of constructive presentation and devoted work upon 
innumerable details, after successfully coping with every hin- 
drance and opposition thus far encountered, her wholesale charity 
plans in the interest of the insane were thwarted, and at the last 
possible opportunity for defeat, by President Pierce, who vetoed 
the bill, thereby, to use his own words, " resisting the deep sym- 
pathy of his own heart in favor of the humane purposes sought to 
be accomplished." He argued that Congress had " power to make 
provision of an eleemosynary character wnthin the District of 
Columbia, but nowhere outside ; that it had transcended its powers 
in those two instances where it had granted public lands to two 
schools for the deaf and dumb; setting up unsafe precedents, 
14 



120 INSTITUTIONAL CARE OF THE INSANE 

examples to be avoided rather than followed." "If Congress has 
power to make provision for the indigent insane without the Dis- 
trict," he continued, " it has the same power to provide for the 
indigent who are not insane, and thus to transfer to the federal 
government the charge of all the poor in all the states." This veto, 
this surprising and inexorable finality, was a cruel blow to Miss 
Dix; the most crushing indeed that she ever experienced. Hosts 
of friends hastened to express their sympathy, and " powerful 
rejoinders " condemning the spirit, as well as the text of the veto, 
appeared in the public press. The President's viewpoint, his logic 
and his conclusions were pronounced faulty, weak and absurd. 
But Miss Dix found little consolation in expressions of good- will 
or daring philippics. The reaction from overstrain, physical and 
mental, was extreme. She lost her nerve, and for the time being 
was unable to proceed with hospital work. 

There remained before Congress another of her bills, one drawn 
to establish the Government Hospital for the Insane at Washing- 
ton. It had then passed the Senate and, as subsequent legislation 
proved, was destined to be enacted before the session closed. But 
such reassuring facts and gratifying prospects were insufficient 
mental tonics to revive her paralyzed courage. Her mind and 
heart, so long subjected to exhausting tension, could not withstand 
the sudden collapse of her long cherished hopes ; she desired noth- 
ing so much as complete rest and in her wretched state of discom- 
fort no proposition having that object in view was so acceptable as 
a foreign tour. Accordingly, within two weeks she was on board 
a steamer bound for England. During the voyage her ruling 
passion for philanthropic work asserted itself. Through her assur- 
ance and extraordinary powers of persuasion she secured posses- 
sion of the pools wagered upon the ship's daily run, as well as a 
liberal contribution from her fellow passengers, all of which money 
was to be turned over to the Home for Seamen's Children. 

Back in Liverpool, entertained by the same devoted friends who 
1 8 years before had lavished comforts and consolation upon her 
during a prolonged season of invalidism, she rapidly regained her 
optimistic spirit, and with it her renewed desire to serve the inter- 
ests of the insane. Within a month she had resolved to investigate 
the hospital conditions in Scotland, though five months elapsed 
before she felt sufficiently recuperated to commence her remark- 




X 

x' 



■k 







J 

< 



^-;;;, f "^, ,:/ : ^ ' % 







W^^ 



DOROTHEA LYNDE DIX AND HER WORK 121 

able exploit in that country. Meantime she rested and enjoyed 
delightful associations with her Liverpool friends, interrupting 
her visit for a few weeks only, while she traveled and visited in 
Ireland. 

In Edinburgh, as was the case everywhere she went, the best 
social circles received her cordially. Such affiliations always gave 
her pleasure, as she repeatedly acknowledged, but no personal con- 
siderations, no local conventionalities or official friendships, could 
divert her humane intent, once she discovered neglect or abuse of 
the insane. Without prejudice against Scottish institutions, she 
began to inspect those in and around Edinburgh. As she expected, 
the more prominent public institutions were well conducted, but to 
her amazement she found that serious abuses existed in the private 
asylums, and that the indigent insane all through Scotland were 
badly treated. Her familiarity with the solution of such problems 
enabled her to comprehend the situation at sight ; and she wrote 
to a friend that, in Scotland, " hundreds of miserable creatures 
were suffering from a bitter bondage, concerning which the people 
at large were quite unconscious." ^ Realizing the importance of 
possessing definite information to form the basis of an aggressive 
public appeal, Miss Dix proceeded to accumulate a record of the 
hidden but damaging facts by a round of personal inspection, just 
as she had done in America. 

To officials and to the general public it seemed presumptuous 
for this non-resident stranger to engage unceremoniously in a 
critical search through their public and private institutions for evi- 
dence of cruelty and injustice towards their irresponsible insane, 
and she encountered much opposition. Her friends, mindful of 
her recent breakdown, urged caution and delay, the mental and 
physical strain attendant upon persistent reformatory work being 
certain, in their opinion, to overtax her impaired health. 

But Miss Dix was under the old spell — a compelling sense of 
duty combined with a prophetic judgment or veritable inspiration 
— and heeded neither the admonition of friends nor the denuncia- 
tion of foes. In explanation of her course, she wrote to a friend 
as follows : " It is true I came here for pleasure, but there is no 
reason why I should close my eyes to the conditions of the most 
helpless of God's creatures. I am confident that this move rests 

^ Tiffany, p. 231. 



122 INSTITUTIONAL CARE OF THE INSANE 

with nie, and the sooner I address myself to this work of humanity 
the sooner will my conscience cease to suggest effort, or rebuke 
inaction." It is pretty clear that I am in for serious work both in 
England and Scotland. I do not see the end of this beginning, but 
everybody says, who speak on this question, that if I go away 
the whole work will fall off. So I pursue what I so strangely 
commenced." " 

In Scotland many influences had retarded the practical applica- 
tion to the insane of the Christian spirit which animated Miss Dix. 
There were, however, many notable, philanthropic Scotchmen who 
painfully recognized the indefensible features of their public policy 
towards the insane. But hitherto their best efforts towards secur- 
ing reforms had failed to accomplish any practical improvement, 
and they gladly welcomed Miss Dix, giving her substantial encour- 
agement in her relentless grapple with public indifference and lax 
view^s of moral responsibility towards the insane. 

In all her attempts to rectify mistreatment of the insane, Miss 
Dix worked quietly until in possession of sufficient incriminating 
evidence to warrant an open attack. She then reported actual con- 
ditions to the responsible managers and higher official authori- 
ties, urging immediate correction of faulty and abusive methods. 
Delayed reformation on their part was severely condemned, and 
grievous facts were then revealed to all interested parties, while 
startling reports and harrowing details appeared in the public 
press. Employing such methods, she soon aroused a reform 
agitation in Scotland, which rapidly extended over the community 
and caused vehement indignation. Despite her able management 
of the cause, however, and the public excitement which resulted, 
she could not secure favorable action from the officials in whom 
was vested ultimate authority over the insane and their manage- 
ment. When she appealed to the sheriff, who was virtually chief 
justice of the high court of the county, he " trifled, jested, pre- 
varicated and ridiculed the idea of reform." 

In time she realized that the Scottish authorities intended to 
defy her, and in a final interview with the local powers Miss Dix 
intimated, or threatened, that she would appeal to the British 
Home Secretary. The Lord Provost of Edinburgh apprehended 

' Tiffany, p. 231. " Tiffany, p. 233. 



DOROTHEA LYNDE DIX AND HER WORK I23 

that her attack signified danger and dreading the eflFect of her 
uncontradicted representation to one of the highest government 
officials of the kingdom, thought it expedient to see the Home 
Secretary himself at once and warn him against the " American 
invader," as Miss Dix had come to be characterized. Appreciating 
the importance of timeliness in attempts to discredit through covert 
methods, such a moral columbiad, he packed his trunk that night 
and early the next morning started for London. 

A judicious precipitancy was a striking feature in many of Miss 
Dix's brilliant achievements. Her incentive in this instance may 
have been the natural outcome of constitutional habits, or a 
clairvoyant interpretation of the lord provost's mental resolutions; 
at any rate, while the crafty politician was sorting out his traveling 
wardrobe. Miss Dix caught up a small hand bag and took the 
evening train for London. She passed a sleepless night, and her 
train was belated, but she arrived several hours in advance of the 
canny Scot, who had aimed to forestall her. This was her first 
visit to London, but she was met at the station by a messenger 
from Lord Shaftesbury, to whom she had wired before she left 
Edinburgh. 

A meeting with this most eminent friend of the insane was then 
and there arranged for the same afternoon. She had three hours 
to wait, but utilized the time in making a call upon the Duke of 
Argyle at Kensington. She stated her business and asked him to 
arrange for an immediate audience with the Home Secretary. The 
Duke was pleased to aid her and presently had arranged an 
audience for her at 4 o'clock. She then drove to keep her appoint- 
ment with Lord Shaftesbury, who had the full Board of Commis- 
sioners with him. With them she discussed the whole subject, out- 
lining the distressing conditions which existed in Scotland, and 
they agreed " that no time ought to be lost in urging the usually 
tardy Secretary." ' Much to her regret the Home Secretary had 
been detained by a council meeting at Buckingham Palace and 
could not see her until the following day. At first, he expressed 
doubt as to his authority to issue a warrant for a commission 
without the sanction of the Lord Advocate of Scotland. But Miss 
Dix was importunate, and persistently sought out lords, dukes and 
commissioners for explanations, consultations and action. Oues- 

^ Tiffany, p. 248. 



124 INSTITUTIONAL CARE OF THE INSANE 

tions involving prerogative and authority had to be duly con- 
sidered in several departments. For a number of days the issue 
was in suspense, but this group of statesmen had been so impressed 
by her statements that neither technicalities nor political expedi- 
ency could suppress a growing demand for an official investiga- 
tion ; and at the end of one week the Home Secretary promised to 
have two commissions appointed, one for the purpose of inquiring 
into the state of lunatic hospitals ; the other to consider the present 
state of the law respecting lunatics and lunatic asylums in Scot- 
land. The order of commission was signed April 19, 1855, by 
Queen \'ictoria. Thus it came about, that seven months after 
.Miss Dix had temporarily abandoned the cause of the insane in 
the United States, physically exhausted and utterly discouraged 
because her omnibus bill for the insane had been vetoed by Presi- 
dent Pierce, she had secured from the English Sovereign a royal 
commission, the observations, reports and recommendations of 
which " actually revolutionized the lunacy laws of the land." 
From all sides, social, political and professional, the credit of 
inaugurating this hospital epoch, so momentous for the insane, 
was unreservedly given to Miss Dix. Addressing Parliament, Mr. 
Ellice said, " The commission was entirely due to Miss Dix's 
exertions," and " no one could read the report of the commission 
without feeling grateful to that lady for having been instrumental 
in exposing proceedings which were disgraceful to this or to any 
other civilized country." The Home Secretary, Sir George Gray, 
who had been such a prominent agent in the commission pre- 
liminaries, gave similar testimony in a speech before the House 
of Commons ; but " deplored the fact that the inauguration of so 
needed a reform should have been left to the initiative of a for- 
eigner, and that foreigner a woman, and that woman a dissenter." 

D. Hack Tuke and numberless other mental specialists in Great 
P>ritain recorded their tributes of appreciation for her marvelous 
capacity for executive leadership, as shown in this movement ; a 
reform which some of their most influential home leaders had 
attempted in vain. 

When the members of the commission had been appointed. Miss 
Dix supplied them with facts and details from her notes, and 
advanced pertinent suggestions which greatly facilitated their 
subsequent investigations. 



DOROTHEA LVNDE DIX AND HER WORK I25 

As soon as the pressure of important events relaxed, her own 
health again became the subject of her chief concern, and she 
sought rest, which was gratefully offered her in the quiet home 
of the Tukes at York, England. That her epoch-making battle 
for the Scottish insane was waged by a semi-invalid appears from 
a confession, written at this time. May, 1855, to her American 
physician and old friend, Dr. Buttolph, at the Trenton State Hos- 
pital : " Counting the time since I left the steamer (about Septem- 
ber 15, 1854) I find that rather more than half the period I have 
been too ill or too languid to do anything." Another paragraph 
in this letter is of especial interest in connection with this sketch ; 
it reads: " I am here in a comfortable, quiet apartment. In the 
room next to mine, retiring from the labors of an active life spent 
in the cause of the insane, lies helpless the good Samuel Tuke." ' 
Another section of this confidential letter illustrates how Miss 
Dix's personal services were frequently called into requisition, and 
the significance she attached to such appeals. While in Edin- 
burgh she met, by chance, Dr. Simpson and his niece, a lady living 
in the south of England, who asked Miss Dix if she had ever 
been in the Channel Islands, especially Jersey and Guernsey ; and 
then gave an account of the abuses to which the insane were 
there subjected, urging Miss Dix to visit the Islands and rectify 
the wrongs. Miss Dix was at that time too deeply engaged in 
the Scottish work to do more than register a mental note in 
regard to the matter, but in this letter she refers to the incident 
as, " What in my case I call leads of Providence." ' 

While she was regaining her strength at York, Dr. D. Hack 
Tuke called her attention to a pamphlet, written by Dr. von 
Leuven, in which the sad conditions involving the insane in the 
Channel Islands were discussed. At her request Tuke wrote to 
the author for more explicit information. A reply came prompt- 
ly, and she says in one of her letters, " The answer determined 
my duty and my next work." Dr. von Leuven had become alarmed 
because some of the most objectionable managers of private mad- 
houses in England, menaced by the hostile public sentiment and 
restrictive legislation which Miss Dix had brought about, were 
re-locating their questionable enterprises in Jersey. It was two 

' Tififany, p. 259. ' Tiffany, p. 260. 



126 INSTITUTIONAL CARE OF THE INSANE 

months before Miss Dix felt able to go to the Island and under- 
take what in a private letter she had predicted she would do there, 
namely, " Helping out of dismal, dark dungeons those whose only 
crime is that they are sick-insane, and so feared and tantalized, 
till they are really what the sane would call them, mad-men and 

mad-women I shall see their chains off. ... I shall take 

them into the green fields, etc." 

The middle of July found her there essaying the benevolent 
mission she had anticipated. The prestige she had gained by her 
unparalleled demonstration of power to influence public opinion 
and legislation in England, added weight to her judgment and dis- 
patch to the execution of her plans. At her instigation, within one 
week's time the local authorities had met in full committee and 
" the resolution was passed to build a hospital for the insane with 
the least possibly delay." A few days later, in a letter to a friend, 
she wrote: " I have got a farm for a hospital I have got- 
ten Mr. (naming a sordid proprietor of a private asylum, 

recently transferred from England) into the hands of the high 
constable of Jersey, by the order of the governor and attorney- 
general. So that business is well settled."' Satisfied that the 
future well-being of the insane in the Channel Islands could be 
safely trusted to local protectors, alert philanthropists and the 
aroused authorities, within a month Miss Dix was away, to join 
old friends in Switzerland. 

After a stay of a few months she resolved to inspect the asylums, 
hospitals and prisons in several other European countries. Ac- 
cordingly by September i she had begun this tour of inspection, 
spending nearly five months in visiting the public institutions of 
Erance. In the main she was satisfied with the conditions she 
found there. Her criticisms were brief and mild. By the middle 
of January she was giving her unsolicited attention to similar 
institutions in Italy. In that country she found the institutional 
care of the insane to be generally bad, and in some instances 
extremely objectionable. When the conditions in any one institu- 
tion warranted her expostulations she always reported the facts 
to the local chief of management, and to augment the force of her 
strictures, she usually filed written protests with the highest 
department or government official. Erom Turin she wrote : 

^ Tiffany, p. 270. 



DOROTHEA LYNDE DIX AND HER WORK IT.'J 

" Made an appointment with the chief doctor for to-morrow, 
.... shall try to represent the importance of entire change for 

the patients shall appeal in writing to the King." ' From 

Genoa she wrote : " I found at Rome a hospital for the insane so 
very bad I set about the difficult task of reform at once, and during 
the 14 days I was there, so far succeeded as to have Papal promise 
and Cardinal assurance of immediate action in remedying abuses 
and supplying deficiencies."" With faith in her mission, as well 
as her judgment, and moral courage equal to any humane demand, 
she had been before the Pope with her remonstrance. Tififany 
narrates the circumstances of this courageous proceeding and 
describes her reception by Pope Pius IX as cordial and con- 
siderate. His Holiness was deeply interested in her account of 
existing wrong towards inmates in the local asylum, and decided 
on the spur of the moment that he would test the accuracy of her 
representations by a personal investigation of the institution in 
question ; and Miss Dix was requested to repeat her visit within 
a few days. Meantime the Pope, without announcing his purpose, 
quietly appeared in the wards, and after a thorough inspection 
became convinced that she had revealed the actual truth. "At the 
second audience granted Miss Dix, the Pope freely acknowledged 
his distress at the condition of the asylum and the treatment of the 
patients, and warmly thanked her, a woman and Protestant, for 
crossing the seas to call to his attention these cruelly treated mem- 
bers of his flock."' A medical commissioner was immediately 
dispatched to France to study the construction and management 
of the best French asylums and within a reasonable limit of time 
the projected Roman hospital for the insane, designed to conform 
in appointment and the treatment of patients with the Dix stand- 
ards, was pushed to completion. 

Assured that in good time such would be the substantial reward 
for her two weeks' labor in Rome, Miss Dix departed for Greece, 
where she spent several busy weeks visiting institutions, to deter- 
mine the standards of care and appointments which prevailed in 
that country. As only scant records of her operations in Greece 
and the conclusions they called forth have been made public, it 
may be presumed that she found little to condemn. 

niffany, p. 285. 'Tiffany, p. 284. ''Tiffany, p. 289. 



128 INSTITUTIONAL CARE OF THE INSANE 

The next stag^e of her somewhat irregular journey ended at 
Constantinople, but she made hurried visits to several institutions 
at intermediate landing-places. Turkish treatment of the insane 
had been so harshly criticized by earlier travelers that Miss Dix 
was prejudiced in advance, and began her inspection of Turkish 
institutions prepared mentally for a strenuous contest with the 
authorities. But she was agreeably disappointed. Excepting one 
debtor's prison, she was admitted to all asylums, hospitals and 
prisons in and about Constantinople ; and the Turkish officials 
treated her with marked civility. Outside the city she discovered 
some asylums where abusive treatment of the insane was tolerated, 
but these were Greek and Armenian institutions. All the Moham- 
medan hospitals were, in her opinion, better managed than the 
asylums she saw in Italy, and the hospital for Turks in Constan- 
tinople was a model, as regards provision for the comfort and the 
amusement of the patients. Dr. Cyrus Hamlin attributes this 
gratifying condition to the work and influence of a Turkish gentle- 
man, who had been so impressed with the conduct of Paris hos- 
pitals that he had copied here, in his native city, the best French 
examples of insane hospital management. ' 

From Constantinople Miss Dix proceeded to Hungary by way 
of the River Danube. She also visited successively Austria, Rus- 
sia, Sweden, Denmark, Holland and Belgium, spending about five 
months on this continuous tour. Along the way she utilized all 
the time at her disposal in observing the internal management of 
public institutions. Miss Dix had but a limited command of con- 
versational French, but through that medium of communication 
and her native English, she made her way in and about these dif- 
ferent countries, each having its special language, making her 
wishes sufficiently comprehensible for her purpose, clearly appre- 
hending the import of all she observed, and invariably successful 
wherever she sought admission. In most places her fame had 
preceded her, so that her name was an " open sesame " to institu- 
tions in all enlightened lands. Applications, where necessary, for 
government passes were honored readily and not infrequently 
such favors were voluntarily proffered. A month before she 
reached Austria her entree to all institutions of the empire had 
been courteously tendered. 

* Hamlin's Letter, Tiffany, p. 302. 







CO 



kM\ 



DOROTHEA LYNDE DIX AND HER WORK 129 

With or without official credentials, Miss Dix explored a suf- 
ficient number of European institutions to satisfy her immediate 
sense of duty, and decided to return to America early in Septem- 
ber. She had been a voluntary exile for two years. When leaving 
her native land she was so exhausted in body and so downcast in 
spirit that prospects for future usefulness seemed dim and remote ; 
yet in these two years she had established the most brilliant record 
of a brilliant career. She had to her credit, not only numberless 
deeds of mercy on a large scale in behalf of the helpless insane, 
but the fact that in the course of her labors she had prevailed with 
a leading imperial government and the world's most eminent 
religious potentate. 

When back in the United States she found her peculiar gifts 
and phenomenal executive ability in greater demand than ever 
before. Requests for her especial attention and efficient services 
poured in upon her from nearly all parts of the Union, and she 
plunged into her work of benevolence with experienced judgment 
and the power of a clarified faith. She was besought for aid in 
securing the enlargement of existing hospitals, for advice in per- 
fecting plans for new institutions and for help in obtaining neces- 
sary appropriations. The respect for her opinion in general was 
such that she was frequently called upon to settle the location of 
a new hospital where conflicting selfish interests had delayed 
action. Candidates for hospital positions desired her endorse- 
ment, and committees on hospital organization often deferred to 
her recommendation in appointing executive officers. 

Though thus burdened with responsibilities for numerous and 
diverse interests, she always maintained her normal composure; 
managed usually to place herself in a commanding position, and 
generally said the appropriate word to the right party at the vitally 
important moment. At different times she found herself sponsor 
for and legislative manager of several important bills, under 
simultaneous consideration in as many dififerent states. The celer- 
ity and apparent ease with which she would, under such circum- 
stances, flit from East to West; from Canada to Texas, as her 
presence was required to advance her many plans, surprised her 
friends and worried those opposing her measures. 

Upon such humane and public-spirited lines she toiled inces- 
santly for five years, and then came the Civil War, which, for 



130 INSTITUTIONAL CARE OF THE INSANE 

the time, checked insane hospital construction in the Xorth as well 
as the South. At the outbreak of hostilities Miss Dix recognized 
new obligations and new duties with her accustomed promptitude. 
The day following the " tumult in Baltimore " with the Massa- 
chusetts regiment, April 19, 1861, Miss Dix was in Washington 
and had ofifered to serve the United States Government in some 
hospital capacity. Because of her world-wide reputation for 
nobility of purpose, her extensive hospital work and her dis- 
tinguished services in the cause of humanity, she was well-known 
and possessed the implicit confidence of the Administration. 
Without hesitation Secretary of War Cameron commissioned her 
as " Superintendent of Women Nurses, to select and assign 
women nurses to general or permanent military hospitals." This 
placed her in an autocratic position, and it has been claimed that 
for a time she exercised her superior privilege in regulating hos- 
pital management. But when the army had been thoroughly 
organized and chiefs of the medical department had seriously dif- 
fered with her, she presumed less frequently or less positively to 
dispute questions of authority with them. 

Noting that ordinary hospital stores were deficient in providing 
the delicacies essential for the comfort, if not for the recovery, of 
the sick in military hospitals, she began to collect clothing and 
medical accessories, refined foods, etc., from the Northern states, 
to be distributed to the sick Union soldiers. Although, at a later 
date, the Sanitary Commission occupied this field. Miss Dix main- 
tained her personal depot to the end of the war, and in that way 
assisted thousands, receiving the gratitude of an army of suffering 
men. 

She often visited the hospitals, especially those in and about 
Washington, and in the East, personally interviewing thousands 
of the wounded. Lossing's " History of the Civil War " pays her 
the following tribute : " Like an angel of mercy this self-sacrific- 
ing woman labored day and night through the entire war for the 
relief of suffering soldiers. She went from battlefield to battle- 
field, when the carnage was over, from camp to camp, hospital to 
hospital, superintending the operations of nurses, and administer- 
ing with her own hand physical comforts to the suflfering, and 
soothing the troubled spirits of the invalid or dying soldier ; always 
burdened with words of heartfelt sympathy and religious con- 



DOROTHEA LYNDE DIX AND HER WORK 13! 

solation. The amount of happiness that resulted from the ser- 
vices of this woman can never be estimated." 

As long as Miss Dix could follow her own views and vary her 
methods to suit changing conditions, she was a decided success, 
but she was not fitted by natural gifts, special training, or the 
experience of her life-work, to plan and control the internal afifairs 
of a surgical hospital, while in selecting nurses she apparently 
deemed moral character the acme of qualifications. Rut in time 
she established an independent position for herself, and the things 
she did to relieve suffering are beyond compute. Although she 
encountered much opposition from hospital chiefs, her good inten- 
tions were never questioned, while her zeal and practical useful- 
ness were universally acknowledged. Nominally she retained her 
commanding rank till the war was over, then Secretary of War 
Stanton, realizing that she would accept no pecuniary recompense 
for her more than four years of laborious service for the benefit 
of the Union soldier, ordered a stand of arms of the United States 
colors to be made for and presented to her, bearing the inscription : 
" In token and acknowledgment of the inestimable services ren- 
dered by Dorothea L. Dix for the Care, Succor and Relief of the 
Sick and Wounded Soldiers of the United States." 

When the Civil War was over Miss Dix resumed her special 
work in the interest of the insane. Her usefulness to the unfortu- 
nate of that class was prolonged for 15 years, but limitations to 
her physical capacity developed as her years increased, while her 
pace slackened and the field of her activities was restricted in cor- 
responding degree. In like manner her personal influence over 
current events in the realm of legislation and insane hospital con- 
struction bcame less and less active, but the powerful under-cur- 
rent of public opinion which she had stimulated into activity and 
directed into practical channels had become a world-wide, irresisti- 
ble and permanent force. 

No attempt to catalogue all her deeds of mercy and her achieve- 
ments for humanity has ever been made, but there are imperish- 
able records in abundance to show succeeding generations that she 
was a power for justice and mercy, and that the wrongs she cor- 
rected can never be re-enacted. There are now standing 32 insti- 
tutions for the insane (according to Tififany) * which were either 

* Tiffany, p. 361. 



132 INSTITUTIONAL CARE OF THE INSANE 

founded outright, or greatly enlarged, as the result of her wise and 
practical efiforts. Tributes of appreciation and respect have been 
engrossed on the archives of 20 states of the Federal Union, as 
well as on those of our Federal Congress, and the Parliament of 
Great Britain. Many societies, representing the best scientific and 
public interest, have placed on their records formal expressions of 
her worth and service. While she was in Scotland, arousing 
public interest favorable to the insane, " The Association of Medi- 
cal Superintendents of American Institutions for the Insane," 
being in session, passed a resolution assuring Miss Dix that she 
was missed from the United States, that her return would be 
" hailed with pleasure," that the Association never met without 
many gratifying recognitions of her invaluable service to human- 
ity, and that she " never held a higher place in our most respectful 
consideration." ^ The choice and able men who composed the 
Association in its early days were her warmest friends ; she was 
always welcome to their official family circle, and was accorded 
every privilege in the wards of hospitals under their control. 

Among those who were proud to befriend and co-operate with 
Miss Dix may be named Bell, Butler, Ray, Buttolph, Kirkbride, 
Earle and Nichols, as well as many others, whose names go to 
form the list of conspicuous American alienists of her times, while 
D, Hack Tuke, John Connolly and numerous other alienists in 
foreign lands recognized her great services in the cause of 
humanity and unstintingly applauded her methods and successes. 

By requests from hospital managers Miss Dix was induced to 
give sittings to artists for 14 life-sized paintings of herself, to be 
placed on the walls of hospitals for the insane, in recognition of 
her work in their behalf, and as a reminder to those who have to 
do with this class of patients that high character and duty well- 
done call for respect and imitation. 

It would be impossible to enumerate all the leaders of public 
affairs, men honored both in America and in Europe, who recog- 
nized her political sagacity and gladly worked under her leader- 
ship in promoting humane legislation for the insane. But the 
greatest fund of generous sentiment, approaching veneration, for 
this noble-minded woman existed in the minds and hearts of 
thousands of less illustrious people, inconspicuous men and women, 

* Tiffany, p. 276. 



DOROTHEA LYNDE DIX AND HER WORK I33 

who enjoyed some blessing derived, directly or indirectly, from 
her unselfish and wisely ordered labors. Such _c;ratitude was indi- 
cated when a landlord in Texas refused pay for her dinner, because 
she had so befriended the poor and unfortunate. " No, no, by 
Georp^e ! T don't take money from you ; why I never thou,2^ht I 
should see you, and now you are here in my house ! You have 
done good to everybody for years and years. Make sure now 
there's a home for you in every house in Texas. Here, wife, this 
is Miss Dix ! Shake hands, and call the children." ' There was 
even a vague disposition to invest her with superhuman qualities. 
She was often termed the " patron saint " of the insane, and hos- 
pital managers instinctively selected the institution chapel as the 
most appropriate resting place for her portrait. 

The wife of the Ambassador to France, Mrs. Walsh, voiced the 
feelings of a large class when she wrote concerning Miss Dix : 
" Such a woman is to be worshipped, if anything human could be 
worshipped." " Considering her humility of spirit, her penetrating 
judgment, her passion for justice, her courage and the compelling 
force of her personality, her biographer argues that her endow- 
ments and achievements rank her with that small class of canonized 
women who lived and molded great events in the earlier centuries 
of the world's history.^ And it is quite probable that in past stages 
of civilization her exceptional gifts of mind and heart, finding 
expression in remarkable deeds, would have been regarded by a 
less well-informed or more superstitious people as miraculous. 

To minds so predisposed there might be a suggestion of pre- 
vision in her words to Mr. Felton, president of the Philadelphia 
and Washington Railroad, in 1861, warning him that a conspiracy 
existed to prevent the inauguration of President-elect Lincoln, and 
that men in the plot were secretly drilling along the line of his 
road, over which the Presidential train was expected to pass. To 
nullify this evil design, Mr. Lincoln was brought into Washing- 
ton secretly hours before the public had been led to expect him. 
Mr. Felton avers in a written statement that he " again and again, 
besought Miss Dix to permit him to make known how much the 
country owed her " in connection with this affair, but she always 
protested against having " any use made of her name." * Again, 

'Tiffany, p. 370. "Tiffany, p. 275. ^Tiffany, p. 290. ^Tiffany, p. 333. 
15 



124 INSTITUTIONAL CARE OF THE INSANE 

how easy, if people were credulous, to infer that she was possessed 
of superhuman power of presaging future happenings, when she 
made that apparently unnecessary trip to the wilds of Sable Island 
and witnessed a wreck on the treacherous sands, through which 
she incidentally discovered the inadequate life-saving apparatus 
provided by the Provincial government. Hurrying back to the 
States she consulted an expert on marine problems and collected 
from her personal friends sufficient funds to purchase four of the 
most approved life-boats, as well as a wagon and other accessories, 
necessary to properly equip the life-saving service. There were 
the usual delays in construction, and the extraordinary misfortune 
of partial loss when delivery was attempted. But, eventually, with 
some new parts and needed repairs, the whole consignment was 
established on the island, providentially as it proved, for in less 
than 24 hours after the arrival of the last, which was the largest 
and the most serviceable boat, an American steamship, having on 
board 180 persons, was driven on the fatal sand-bar by an ocean 
tempest. According to Dominion authorities none of the Island's 
boats could have lived in the strong gale and heavy seas which 
prevailed, but the Dix boats landed every individual. " My dear 
Miss Dix," wrote Miss Gurney, " I congratulate you intensely ; 
I never heard of such a success, and to have it exactly the day 
after your boat arrived." ' The Honorable Hugh Bell, of Hahfax, 
wrote her in the same tenor, and added, " will you not rejoice at 
this result of your bounty ? " ' Her response to this suggestion of 
personal pride was exactly what might have been expected. With 
her habitual modesty and the superior poise which won her such 
universal appreciation, such triumphal leadership and such pro- 
found admiration, she hastened to give all credit to others con- 
cerned, immediately filing with the Mariner's Benevolent Society 
of London a statement detailing the disaster and the meritorious 
conduct of the life-saving crew, each member of which was duly 
awarded a medal in token of heroic services on that occasion. Her 
mental attitude in this connection exhibits the dominant traits of 
her character. Always thinking of and working for others, she 
sought no man's thanks, and seemed to be actually embarrassed 
when persons whom she had aided attempted to express their 
gratitude. 

' Tiffany, p. 225. ' Tiffany, p. 221. 



DOROTHEA LYNDE DIX AND HER WORK I35 

She was repeatedly urged to give the world an autobiography, 
but she could not entertain the proposition because it involved self- 
satisfaction and self-praise. All through her life she had intimate, 
confidential friends to whom she occasionally wrote in detail re- 
garding matters which, for the moment, engaged her interest, but 
a request that such personal revelations be destroyed was usually 
appended. In many instances her injunction was ignored, and with 
such letters of this kind as were preserved, together with those 
from friends received and treasured by her, her biographer was 
able to construct a very interesting volume. 

Her powerful imagination had, no doubt, much to do with fitting 
her for the great part she played in human affairs, but the con- 
trol she exercised over it shows the advantage she derived from 
practical mental discipline. Passages in her early letters sug- 
gest that, when a school girl, her youthful imagination led her to 
extremes in religious experience, and that she almost realized the 
religious ecstasy resulting from mystical introspection and beatific 
aspiration. To a friend she wrote, " It is not that I would win the 
world's applause, or that I would possess a mind above the com- 
mon sphere, but that I might have the luxury of those mental 
visions that must hourly entrance a spirit that partakes less of 
earth than of Heaven." ^ Fortunately her diffuse and intense 
religious feeling was so quickly regulated by her disciplined rea- 
soning powers that all undue excitement was suppressed and her 
excess of emotion, prevented from exhausting itself in exaltation, 
was directed into altruistic endeavor. As a consequence the trend 
of her imagination became thoughtful and serious, rather than 
fanciful and romantic, and by the time she commenced her life 
work for the insane she had eliminated from her mental equip- 
ment whatever did not savor of wisdom or appeal to sound judg- 
ment. 

Miss Dix contended with invalidism during the greater part of 
her life, and yet she lived to be 85 years old, dying in 1887. 
During the last five years of her Hfe she was physically incapaci- 
tated, but her mind was unimpaired. To the last she retained an 
absorbing interest in everything affecting the insane, and cheer- 
fully employed her enforced leisure in conversation with visitors, 
friendly correspondence and reading, especially enjoying devo- 

* Tiffany, p. 25. 



136 INSTITUTIONAL CARE OF THE INSANE 

tional literature. Domiciled in the Trenton State Hospital, with 
every need supplied, she could have written volumes of reminis- 
cences of surpassinj^ interest and great permanent value, had she 
been minded to dwell upon the past, but she adhered to her life- 
long principle and persisted in looking forward. 

Two years before her death she wrote to a surviving member 
of the Whittier family, at Oak Knoll, Danvers, requesting a writ- 
ten copy of " that heart penetrating poem of Mr. Whittier's, 'At 
Last.' " And this manuscript co])y was found, after her death, 
under her pillow, and was read at her burial in Mt. Auburn Ceme- 
tery.' This much worn copy, kept always close at hand, suggests 
how frequently her thoughts must have been occupied with the 
sentiments that form the subject of the verses beginning: 
When on my day of life the night is falling, 

and ending : 

There, from the music round me stealing, 
I feign would learn the new and holy song, 

And find at last, beneath Thy trees of healing. 
The life for which I long. 

Certainly no description could more fittingly apply to her in 
these latter days than the significant words found in a letter of 
her own, written 32 years before to Dr. Buttolph, in which she 
describes the " good Samuel Tuke," then waiting for his final 
reward: "The Angel of Death stands at the door waiting; but 
the great blessing is deferred, the entrance into immortal life, 
where no clouds obscure the thought, nor hinder the spirit's 
growth." 

' Private letter to Mrs. Woodman. 



CHAPTER IV 
METHODS OF CARE IN INSTITUTIONS 



EVOLUTION OF INSTITUTIONAL CARE IN THE 
UNITED STATES. 

Prior to the nineteenth century the care of the insane in America 
was lare^ely a local enterprise. There are records which show 
that in the early history of New York City the insane were cared 
for in an almshouse situated near the present City Hall, which had 
been built under the old Dutch administration and was designed 
primarily for the care of the friendless and destitute, both young 
and old. but at that period such an institution, though originally 
intended for the poor and friendless, was sure to become a recep- 
tacle for insane persons who could not take care of themselves or 
were unfit to be at large on account of dangerous propensities. 
The successor of this almshouse, which stood at that time on Kips 
Bay, East River, on the site of the present Bellevue Hospital, was 
also used for the care of the insane prior to the establishment of 
the insane department of the New York Hospital. 

In Philadelphia, as wall be seen elsewhere, the Pennsylvania 
Hospital was originally established to provide for the homeless 
friendless insane as well as for the sick who had no place in which 
they could secure treatment. It is true that the provision at the 
Pennsylvania Hospital consisted merely of cells in the basement 
and was only intended for persons who required custodial care. 
However, it is impossible to read the account of the Pennsylvania 
Hospital contained in Morton's excellent history, published at its 
sesquicentennial in 1901, without being convinced that the care 
and treatment furnished for the insane were fully equal to what 
were then supposed to be the requirements of such patients. There 
is no record, either in England or America, or upon the continent 
of Europe, of any provision for the insane at that date beyond 
custodial care. The safekeeping furnished by the small, incon- 
venient, ill-ventilated and, to modern ideas, wholly inadequate cells 
in the basement of the Pennsylvania Hospital included all that the 
mind of the public or of the medical profession conceived to be 
necessary. 



140 IXSTITUTIONAL CARE OF THE INSANE 

It has been claimed that at IMockley Ahnshouse, now known as 
the Philadelphia Hospital, earlier and better provision existed. 
There is, however, no reason to think the institution was then 
other than an almshouse, such as provided shelter everywhere for 
the chronic insane, as well as haphazard and temporary accommo- 
dation for violent emerj^ency cases. If any well-considered plan of 
caring for the insane in connection with the l>lockley Almshouse 
had existed, surely Benjamin Franklin and his co-workers would 
not have appealed to the General Assembly of Pennsylvania in 
175 1 for funds to be employed in the erection of the Pennsylvania 
Hospital avow^edly to take care of the insane. 

It is well known that in many states the contract for the care of 
the pauper insane, notably in New England, was awarded annually 
to the lowest bidder. This was not due to the fact that the insane 
were less considered than other dependents ; it was the custom thus 
to make annual provision for the care of paupers. In Connecticut, 
Massachusetts and New Hampshire the insane poor, being classed 
as paupers, were annually sold at auction to those who were willing 
to assume the care of such confessedly undesirable persons for a 
money consideration. Wherever it was not practicable to procure 
care for them in private families it was customary to confine vio- 
lent, dangerous or untidy lunatics in jail or sometimes at home, in 
a strong pen, under the care of relatives. 

It is especially interesting to note that in localities where the 
insane were cared for in this imperfect manner their condition 
appealed to the benevolent and philanthropic, and efforts were 
made by individuals to endow institutions for their better care and 
treatment. The Pennsylvania Hospital department for the insane 
thus founded developed into the present institution in West Phila- 
delphia, which has had an honorable and useful career for more 
than 70 years. The insane department of the New York Hospital 
became the present Bloomingdale Hospital at White Plains, N. Y., 
through a similar growth and development. In Connecticut the 
Hartford Retreat, established by the State Medical Society, did 
excellent service in caring for the insane during a period of 40 
years previous to the construction of the State Hospital. The 
same is true of Butler Hospital at Providence, R. I., which owed 
its establishment to private benevolence and for many years cared 
for the insane who needed hospital care under a contract with the 




i6 



EVOLUTION OF INSTITUTIONAL CARE IN THE UNITED STATES I4I 

State. In Boston, the McLean Hospital, a department of the 
Massachusetts General Hospital, performed a similar work for the 
state until such time as the Worcester State Hospital, a direct out- 
growth of the Hartford Retreat, was established. In Vermont the 
charity of Mrs. Anna Marsh and her modest bequest of less than 
$20,000 gave birth to the Brattleboro Retreat, which was used by 
the state for the care of its insane for nearly 50 years and rendered 
the building of a state institution unnecessary during that period. 
In New Hampshire the State Hospital remains to this day a cor- 
porate institution, which provides for state patients and receives 
cases from the whole state. It is a matter of pride and satisfaction 
to lovers of humanity that enlightened private benevolence in many 
cases paved the way for proper state care of the insane. 

In a few states mixed state and county provision for the insane 
existed from the start. In some instances county hospitals devel- 
oped, because it was not practicable to induce the state to build 
a hospital sufficiently large to accommodate all the insane of a 
municipality or county. This w^as formerly the case in the State of 
New York. Many county hospitals for the insane poor were built 
in large cities, like New York, Albany, Rochester, Buffalo, Rome, 
Hudson and others, to provide for patients returned from state 
institutions or to accommodate cases which could not be admitted 
to them, or to serve as detention hospitals. Soon, however, owing 
to the vitality which local institutions even of this character sooner 
or later acquire, they became permanent, being encouraged and 
developed by local authorities in order that they might take the 
place of state hospitals. 

In New York, after the enactment of state care, the inmates 
of such county and municipal hospitals for the insane were trans- 
ferred to those belonging to the state, and the hospitals were con- 
verted to other uses, as at Rome, where a large county receptacle 
for the insane became an institution for chronic cases under state 
care ; or as at Rochester, where the county hospital became a state 
hospital for the insane in the modern sense ; or as at Buffalo, where 
a county institution was retained by the county and became a hos- 
pital for tuberculosis. Other states have had a somewhat different 
experience. In Michigan, for instance, an institution for the 
insane built at Eloise, near Detroit, still retains its individuality 



142 INSTITUTIONAL CARE OF THE INSANE 

as a county institution, but receives a subsidy from the state for 
the care of state patients. 

In Illinois the institution established by Cook County, at Dun- 
ning, for the insane of Chicago and the vicinity, has been converted 
into a large state institution, and is wholly free from city and 
county control. In Delaware the state was for many years unwill- 
ing to build an institution for the insane, but finally at Farnhurst, 
near the City of W'ilmington, it acquired rights in a county infirm- 
ary, which was afterwards developed by the state into a well- 
ordered institution for the state care of all of her insane. In New 
Jersey a number of county institutions sprang up for precisely the 
same reasons as in New York, namely, the inadequacy of state hos- 
pitals and the necessity of providing for the chronic insane in their 
home counties in order to relieve the state hospitals from pressure 
and to ensure accommodations within them for acute cases. 

The history of Pennsylvania shows a backward tendency in 
consequence of a lack of forethought in the state's eflfort to care 
for her insane. State care was decreed prematurely, before suf- 
ficient institutions had been provided to accommodate the insane, 
with the result that all of them became hopelessly overcrowded and 
could not receive patients when application for admission was 
made to them. It became necessary, therefore, to increase the 
capacity of state institutions or else to license county institutions 
for the reception of state patients. As a result many counties in 
Pennsylvania have erected asylums under a law by which a cer- 
tain proportion of the expense of building is reimbursed to them 
by the state and a weekly sum is received for the support of 
patients. The custody of the insane has thus become a source of 
revenue to the county, a mistaken policy that has tended to develop 
county institutions, which are now more firmly established than 
ever ; but it has not improved the care of patients. What the result 
may be cannot now be foreseen. 

A similar state of aflfairs exists in Wisconsin. In that state 
about 30 years ago, in order not to increase the size of the two 
state institutions for the insane, two classes of patients only were 
provided for : those of recent disease, who required special medical 
care and treatment, and those who were dangerous to themselves 
or others, so that their presence at a county institution was a 
menace to the inmates and their care a source of unusual expense 



EVOLUTION OF INSTITUTIONAL CARE IN THE UNITED STATES I43 

and difficulty. Under the supervision of the State Board of Con- 
trol it became lawful for such counties as had a large number of 
chronic patients to build county asylums. Provision was also 
made by the state to pay a certain stipend to the county for the 
care of all patients maintained by it. It is claimed by its advocates 
that such county provision permits cases of chronic insanity to be 
cared for near their friends and to be visited by them more fre- 
quently than is possible at a state hospital at a distance ; they have 
also, it is urged, better opportunities for congenial occupation and 
useful labor near their homes. On the other hand, it is asserted 
that under this system a county institution becomes a source of 
income to the county and that in some instances where patients 
are admitted from other counties the whole institution is main- 
tained on the subsidy received from the state. A still more 
lamentable effect of the division of state and county care has been 
the lowering of the standard of care in the state institutions in 
Wisconsin. As the subject will be fully discussed elsewhere,' I will 
not refer further to the so-called " Wisconsin system." 

In the opinion of the writer, a vital mistake was made by many 
states, especially by those which copied their methods from New 
York, in permitting the county a controlling voice in the disposi- 
tion of the insane. In other words, many of the abuses which 
have arisen owe their origin to the fact that the insane have been 
classed as paupers, and not as hospital patients requiring special 
care. In Xew York, Michigan, Minnesota and other states, it was 
customary, when placing indigent insane patients in an institution, 
to recognize them as patients chargeable to the county of their resi- 
dence and to compel it to pay for their care. It would have been 
wiser to consider them wards of the state from the moment of their 
admission to a state institution. 

^ See page 168. 



II. 

COUNTY CARE OF THE INSANE. 

As has been pointed out in another section, the care of insane 
patients in counties originated when no suitable provision existed 
for their care elsewhere. They were homeless and dependent, and 
therefore objects of public charity, and they were cared for in 
almshouses as preferable to putting them in jails or confining them 
in pens or cells at home. County care was at first only an emer- 
gency provision and was so regarded. Almshouses for the care of 
the insane poor were established in the towns of Rhode Island. 
Connecticut and other New England states, as well as in a few 
counties in New Jersey, where the insane as well as any other per- 
sons who required custody were cared for under the charge of the 
selectmen. There was no thought on the part of the officers who 
took charge of the insane in this manner that such care would be 
other than temporary. In states where the county system of caring 
for the poor prevailed, which was generally the custom outside of 
New England, the insane poor were placed in county almshouses 
or in adjacent apartments especially arranged for them. Accord- 
ingly, in the history of every state we get records of town or 
county provision for the insane. Such provision was not organ- 
ized into a system until it became necessary to provide for patients 
of a chronic class, who needed to be removed from state hospitals, 
designed for the care of acutely insane persons, in order to make 
room for more hopeful cases. As soon as chronic cases began 
to be removed, it became necessary for county superintendents of 
the poor to provide accommodations for them, which was eventu- 
ally done by erecting buildings for the custodial care of the insane 
as departments of existing almshouses. These buildings were con- 
structed at first to meet the exigency which had arisen and to pre- 
vent the state hospitals from becoming blocked by chronic cases. 
In addition to township and county care, there grew up in large 
cities a system of municipal care ; for example, in Boston, the 
Boston Lunatic Hospital ; in New York, the hospital on Black- 
well's Island ; in Philadelphia, the Philadelphia Hospital, better 
known as the Blockley Hospital ; in Chicago, the Cook County 



COUNTY CARE OF THE INSANE 145 

Hospital at Dunnin^c: : in Detroit, the Wayne County Hospital. 
These and other similar institutions built for the care of the insane 
of cities were avowedly for the care of all classes of the insane, 
both chronic and acute. 

In order to improve almshouse conditions state boards of charity 
were established about this time in many of the states, which began 
their work by the inspection of existing conditions. The agents 
or members of these boards in New York, Massachusetts, Ohio, 
Michigan and other states found much to criticise and condemn in 
the conduct of these county establishments, and their criticisms, 
in many instances, caused county officials to build better institu- 
tions for the custodial care of the chronic insane, arranged some- 
what on the plan of the earlier asylums or hospitals. In these' 
the physical care of patients was often fairly good, but medical 
care, supervision and nursing were very generally neglected. The 
conditions which existed in New York are well shown by reports 
made by physicians in every county, collected in 1865 through the 
efforts of the New York State Medical Society. These impartial 
reports showed a condition of affairs which appealed strongly to 
the public conscience and finally resulted in the establishment of 
the Willard State Hospital for the chronic insane. 

In New York, however, as well as in other states, county officials 
were reluctant to do away with institutions which had been built by 
local taxes, often at considerable cost. Local influence also was 
often exerted to keep the chronic insane in county institutions, 
because of a small amount of patronage and pecuniary advantage 
presumably involved in the local management. 

Objections to the county system were numerous and of great 
weight. Its greatest fault was the fact that there was no uni- 
formity in the care bestowed upon patients, nor was there any 
standard of care. Each county asylum was managed by local men, 
generally without experience or adequate training and with only a 
limited knowledge of the requirements of such an institution. 
They were not under the control of medical men and their manage- 
ment was more apt to be governed by considerations of economy 
rather than of humanity. In consequence of these conditions, as 
many systems of management were evolved as there were counties, 
and the insane thus sheltered failed to get uniform care or adequate 
or proper treatment. 



146 INSTITUTIONAL CARE OF THE INSANE 

In one state, Wisconsin, the care of the insane in counties was 
adopted as a policy of the state and became a definite part of the 
state system for the insane. Full particulars of this mode of care 
will be given in another chapter. It is sufficient to say here that 
the system has had many advocates in Wisconsin and many critics 
elsewhere. The example has been followed to a limited extent in 
other states, but the consensus of opinion seems to be that state 
care is preferable to any system of county care, however excellent. 



III. 

CHRONIC AND INCURABLE INSANE. 

Up to the year 1864 no special provision had been made for 
the chronic and incurable insane. In New York, where the first 
steps in this direction were taken, it was not compulsory to send 
an insane person to a place of treatment (criminals excepted) or 
even to a place of detention. There was, in fact, a provision in the 
lunacy laws which permitted or rather required the medical super- 
intendent of a state asylum, at the expiration of a certain period, 
generally thirteen months, to return the patient to the care of the 
county poorhouse, if, in the judgment of that officer, the patient 
was incurable or was a case of chronic mental disease not likely to 
be improved by further treatment. At this time the county poor- 
house of earlier days had not undergone much change. It received 
the honest as well as the vicious poor, orphans, abandoned children, 
idiots, degenerates, and the aged and infirm, together with the 
insane, all under one roof, with limited facilities, or, it might be, 
with no facilities at all for classification. The insane were of neces- 
sity much restricted in their liberty and were often confined in cells 
under mechanical restraint with leather muflfs or irons, besides 
being subject to abuse and neglect. The practical administration 
of the laws produced a separation of the insane into two classes, 
namely, the recent and probably curable, and the chronic and prob- 
ably hopeless, the question of the final disposition of each class 
being decided largely by the cost of maintenance in a hospital, if 
troublesome, or in an almshouse at a considerable reduction of 
expense, if quiet, a poHcy which was yearly adding to the number 
to be maintained in houses already overcrowded. 

The system of county care of the insane had become so thor- 
oughly intrenched by usage and patronage that it had survived two 
public exposures in which the counts of the indictments alleged 
abuse, deficiencies, and neglect. But in 1864 the State Medical 
Society of New York approved a recommendation for the appoint- 
ment of a commission empowered to visit all asylums and poor- 
houses in which the insane were confined and further resolved to 



148 INSTITUTIONAL CARE OF THE INSANE 

appoint a committee of the society to confer with the commission 
appointed by the Senate and Assembly. This committee consisted 
of Drs. Charles A. Lee, S. D. Willard and George Cook. The 
joint committees formulated a bill directing the county judges of 
every county in the state to appoint a physician of the county to 
visit the poorhouses and report upon the situation and condition of 
the insane confined there, the report to be sent to the secretary of 
the State Medical Society, Dr. S. D. Willard. The various reports, 
53 in number, formed the basis of a further report which Dr. Wil- 
lard presented to the Legislature, with recommendations, on Feb- 
ruary 5, 1865. 

The Governor of Xew York, Reuben E. Fenton, in transmitting 
Dr. Willard's report to the Legislature, pointed out that in 53 
counties, not including New York and Kings, there were 1345 
lunatics confined in poorhouses, or poorhouse asylums, nearly all 
of whom were incurable, while many had become and others were 
fast becoming incurable from inefficient care and treatment. " The 
time has come," he said, " when legislative provision for them 
should be made. The propriety of establishing an institution for 
incurables — an institution that shall relieve county authorities 
from the care of the insane — should be deliberately considered." 

" More than one-fourth of this number of insane," he continued, 
" are capable of some kind of labor. To what extent that labor, 
organized and systematized, might be made productive in the 
maintenance of an institution under well-directed medical superin- 
tendence is likewise worthy of consideration." 

In accordance with Governor Fenton's recommendation. Dr. 
William H. Richardson, of Essex County, chairman of the Com- 
mittee of Public Health, introduced a bill entitled " An Act to 
Authorize the Establishment of a State Asylum for the Chronic 
Insane and for the Better Care of the Insane Poor, to be Known 
as ' The Willard Asylum for the Insane,' " which became a law on 
April 5, 1865. This bill contained the positive requirement that 
" the chronic pauper insane from the poorhouses and all chronic 
pauper patients that shall be discharged not recovered from the 
State Lunatic Asylum (Utica) shall be sent to the asylum hereby 
created," thereby preventing their transference to the county poor- 
house, as had been the legal disposition of them up to this time. 



CHRONIC AND INCURABLE INSANE I49 

The enactment and application of the principle of the " Willard 
law " was the entering wedge in a scheme destined eventually to 
supplant the system of county care and later to establish the pres- 
ent system of state care in its place. 

During the consideration of the bill Dr. Willard died in March, 
1865, but his name and his memory are perpetuated in connection 
with the hospital he was instrumental in creating. 

Drs. John P. Gray, John B. Chajiin and J. T. Williams were 
appointed by Governor Fenton commissioners to locate the asylum, 
prepare plans for its construction, and erect the buildings. The 
property selected for its site had formerly belonged to the State 
Agricultural College. It was situated near the village of Ovid, 
on Seneca Lake, and the title to it was acquired in December, 1865. 
In the spring of 1869 the Legislature abolished the building com- 
mission and conferred its powers and duties upon a board of 
trustees. The trustees appointed Dr. John B. Chapin to be super- 
intendent of the asylum and on October 13, 1869, the first patients 
were received from Columbia County. 

It was anticipated that the patients selected for transference to 
the asylum would represent various mental and degenerate condi- 
tions, and the commissioners bestowed careful attention upon a 
scheme which should meet these conditions. It was necessary in 
their opinion to make a departure which in some respects would be 
radical, but which nevertheless seemed fully warranted by existing 
intolerable conditions. Their governing intentions were to remove 
chronic or incurable cases among the pauper insane from the 
poorhouses, to devise improved plans for their housing which 
should lessen the per capita cost of construction and by aggrega- 
tion of numbers reduce the cost of support ; to avoid duplication of 
service, and, lastly, to establish as a principle the humane dis- 
position of the insane under responsible professional supervision 
and state care. All of these objects were accomplished by the 
erection of groups of detached buildings which were found to 
cost two-thirds less than accommodation prepared in accordance 
with plans usually adopted. The " Willard law," so called, may 
be said to have fairly accomplished the work its friends set 
out to perform through it, and its indirect influence, by the sub- 
stitution of supplemental buildings, or blocks, or cottages, in place 
of large congregate structures, has been widespread and has con- 



150 INSTITUTIONAL CARE OF THE INSANE 

tributed greatly to the present comprehensive system of state care 
of the insane in New York. Moreover, by means of it the supreme 
power of the state, which had hitherto been exercised over the 
estates and persons of orphans and destitute children, was ex- 
tended, so as to include the insane and whatever might conduce to 
their welfare. The recognition and adoption of this principle, 
together with its enlarged application according to modifications 
made by succeeding legislation, are to be recorded among the 
humane and scientific achievements of the age in which we live, 
by which the most cherished desires of the friends of the insane 
have been realized. 

In June, 1865, at a meeting of the Association of Medical Super- 
intendents of American Institutions for the Insane, the question of 
caring for the indigent and incurable insane was introduced by Dr. 
Butler, of Hartford, Conn. He said that in former years special 
provision had been made for the curable insane, but at that time 
there was no thought of conditions which had since then arisen, 
involving the necessity of providing for chronic and incurable, as 
well as acute forms of insanity. In Connecticut, at the time he 
spoke, there were fully 500 cases, which, although incurable, 
needed hospital care, and he asked: What should be done with 
them? Two methods of providing for them, he said, suggested 
themselves to him : First, that separate institutions should be 
built for incurable cases, a plan which he feared was impossible. 
Second, that farms should be provided for the permanent disposi- 
tion of incurables, where their labor might partially meet the 
expense of their support. 

In the discussion which followed considerable disinclination on 
the part of members was developed towards drawing any line of 
distinction as to provision or treatment between incurable and cur- 
able cases. Dr. Chipley, of Kentucky, was opposed to any classi- 
fication which did not exist in well-regulated hospitals. He had 
known many patients who had been apparently incurable for 
years and yet who had recovered ; he hoped never to see establish- 
ments for the insane under the charge of keepers and the old 
arrangements for the care of incurable patients. If the insane 
were to be cared for on farms, why should not the farm be 
connected with institutions already established? He wisely 
thought that the question of profit from the labor of inmates of 
institutions should never be entertained. 



CHRONIC AND INCURABLE INSANE I5I 

Another member, Dr. Hills, of Ohio, felt that though in Ohio 
the institutions had been increased in number, the increase of the 
insane had been greater in proportion, so that not more than one- 
half of the insane of the state were at present cared for in state 
institutions, the remainder being provided for in workhouses, jails, 
or under the care of their friends. He believed it to be wrong to 
reject a curable case from admission to an institution in order to 
keep an incurable patient under treatment. Dr. Gundry asserted 
that the idea of separating the insane into two classes might appeal 
to the political economist who could comprehend nothing beyond 
dollars and cents, but by professional men it must be viewed dif- 
ferently ; he contended strongly that all insane persons must be 
cared for ; he did not believe that incurable patients could with 
safety be withdrawn from institutions because their presence was 
valuable in aiding curable cases. He thought that separation would 
be injurious to the interests of the insane generally. Dr. Kirk- 
Ijride also believed separation to be wrong. 

xA.s a result of the discussion a resolution was adopted appointing 
a committee of three to take into consideration the condition of 
the chronic incurable insane and the best possible arrangements for 
their custody and to make a report to be submitted at the next 
meeting of the Association. 

At the next meeting of the Association at AVashington in April, 
1866, the committee thus appointed reported a series of resolutions 
and a paper was read by Dr. George Cook on " Provision for the 
Insane Poor of the State of New York," which covered much the 
same ground as previous papers. The report and paper evoked an 
extended discussion from Dr. Brown, of Bloomingdale Hospital, 
from Dr. Van Nostrand, of Wisconsin, Dr. Walker, of Boston, 
Dr. Peck, of Ohio, Dr. Ranney, of Iowa, and Dr. Gray, of Utica, 
The last of these made an earnest plea against the separation of 
the chronic from the acute insane, urging that the State of New 
York be divided into three hospital sections and that each hospital 
be provided with separate buildings for chronic and incurable 
cases, located largely upon farms in order that the labor of the 
insane might be utilized to assist in their support. 

The discussion continued throughout two days and considerable 
feeling was excited among the members. Finally, a resolution pre- 
sented by Dr. Cook providing for the separation of curable and 



152 INSTITUTIONAL CARE OF THE INSANE 

incurable patients in institutions of different grades was defeated 
and the resolutions proposed by the committee were adopted in a 
modified form. They recommended that ample and suitable pro- 
vision for both classes of patients alike should be made in every 
state. 

It is interesting to note at the present time, after a lapse of 
nearly 50 years, that the majority of efforts to divide the insane 
into two classes, chronic and incurable, have failed and that the 
institution at Willard, designed wholly for chronic cases, has for 
years been used as an institution for the treatment of all classes of 
the insane developing in the district composed of counties adjacent 
to it. It now forms one of the 13 institutions of New York 
devoted to the care of both acute and chronic insane. 

In connection with this discussion the Journal of Insanity pub- 
lished an elaborate editorial, probably prepared by Dr. Gray, as a 
comment upon the paper of Dr. Cook. In this occurs a letter writ- 
ten by Dr. Brigham, then at Utica, to Aliss Dix, which is worthy 
of reproduction. He said : 

After much consideration, I feel constrained to oppose the establishment 
of hospitals solely for the incurable insane. They would, in my opinion, 
soon become objects of but little interest to any one, and where misrule, 
neglect, and all kinds of abuse would exist and exist without detection. I 
am opposed to them ; principally on these grounds : 

1. Who can say which patients are and which are not incurable? Of 
200 now in this asylum (Utica) neither Dr. Buttolph nor myself, nor any one 
else, can say of at least one-third to which class they belong. There is hope 
in their cases, but this hope would be destroyed by sending them to an 
incurable establishment. The fact that the chance of recovery would be 
diminished to even a few is enough to make us hesitate before establishing 
such asylums. 

2. Many that are incurable are monomaniacs, that are deranged but on 
one or two subjects, but rational on others; such surely should not be 
deprived of any comforts that are afforded to the curable class, among 
which the greatest is the hope of again being restored to society, which 
would be destroyed if they were sent to an incurable asylum. Equally, or 
more strongly, does this objection apply to cases of remission — to those 
numerous cases in which insanity is exhibited for a week and followed by 
several weeks of sanity. Shall these be told there is no hope for them? 

3. Among the incurable insane there would be no certain means of 
ascertaining the neglect or abuse of them. In all asylums the fact that some 
are well and soon to leave the asylum is the greatest safeguard against 
abuse. It is so considered by all who are much acquainted with asylums 
for the insane. 



CHRONIC AND INCURABLE INSANE 153 

4. No possible good would arise from such district asylums except they 
might be conducted at less expense. But how so, if they are to have proper 
officers, physicians, etc.? and if they do not, why are they better than county 
houses? 

5. We have had no experience of such establishments. I have never 
seen but one such, and that was at Genoa — where the clashing of chains, 
the howling, groans, and curses gave to the place the appearance of the 
infernal regions; where no patient is ever expected to leave until dead; 
where hope never comes. 

No, do not, in mercy to the insane, establish asylums for the incurable 
alone, but provide good asylums for all, and let all have the same kind 
care, and indulge the same hopes (even if delusive to many) of ultimate 
recovery, but do not drive them to despair by pronouncing them incurable. 

An elaborate paper from Dr. John B. Chapin, the first superin- 
tendent of Willard, was also published in the Journal in which he 
makes a strong defense of his plan to provide for the chronic poor 
insane of the state, not on the ground that it is the best method of 
providing for them, but because the experience of New York and 
of other states has been that it is not possible to induce the state 
to provide for chronic patients in the more expensive institutions 
arranged for and especially built for acute cases. He saw no other 
way of preventing the lamentable discharge of chronic cases to 
poorhouses than to provide a cheaper grade of accommodations in 
connection with a separate institution. He made it clear that the 
object of those who urged the Willard law was to take the chronic 
insane poor out of the county almshouses and to provide for them 
in state buildings under state care so that their condition might be 
made as comfortable as possible. 

He cited the experience of other states, like Massachusetts, and 
the province of Ontario in Canada, in support of his project and 
believed that the establishment of Willard would mark a distinc- 
tive advance in the care of all the insane of the state. 

Immediately following this article was one by Dr. Benjamin 
Workman, assistant superintendent of the Lunatic Asylum at 
Toronto, in which he gave figures in reference to overcrowding of 
institutions for the acute insane in Canada and the necessity of 
providing for incurables (in 1859) in branch asylums, at a distance 
of three miles from the central institution, under the care of a 
steward and matron with a sufficient staff of attendants and facili- 
ties for utilizing their labors. He also spoke of providing a branch 
asylum at ^Maiden, in which there were 200 patients with a qualified 
medical superintendent. 



154 INSTITUTIONAL CARE OF THE INSANE 

He added that in 1861 a half-finished brick hotel in the village 
of Orillia had been purchased and fitted up, to which 132 patients 
were transferred from Toronto. Notwithstanding all these efforts 
to care for the insane, there were, at the date of writing, more 
than 200 applications from patients who could not be admitted, and 
two wings were being built to enlarge the Toronto Hospital, thus 
furnishing accommodations for 250 additional patients. He called 
attention to the fact that these branches were not placed under 
county or municipal management, but, being under the care of the 
province, were subjected to the same visitations by inspectors as 
other institutions. He also pointed out that branch asylums for 
chronic cases have to a limited extent been curative, and that 
patients have been made very comfortable in them during the 
year. 

As to the question of the profit to be derived from the labor of 
chronic insane patients, he said that while such labor is valuable, 
especially in farming operations wherever an auxiliary is estab- 
lished, it cannot be made so profitable as to render the institution 
self-supporting, since whatever work is done must be done under 
certain disadvantages, and necessitates the supervision of experi- 
enced persons. The form of labor which he considered most desir- 
able is that upon a farm. Finally, he direw the following 
conclusions : 

1. That the branch institutions for the chronic insane above referred to 
have secured to the inmates non-restraint methods almost entirely, a general 
cheerful condition of comfort, and a good diet. 

2. That they have been conducive to recoveries, which might not have 
occurred had not the patient been sent to these institutions, where a freer 
life was possible. 

3. That their hygienic conditions have been satisfactory and the mortality 
rate has been small. 

In this connection, as foreshadowing a boarding-out system and 
the establishment of colonies for the chronic insane, an article by 
Dr. Pliny Earle " On Prospective Provision for the Insane," pub- 
lished about this time, is of much interest. In this Dr. Earle 
declares : 

1. That some quiet, incurable patients, can be as well taken care of in their 
own homes as anywhere else. 

2. That as there are not a few who have no homes, but who do not require 
the restraint of an institution, they can be well cared for in connection 
with respectable people who wish to take them as boarders. 



CHRONIC AND INCURABLE INSANE 155 

3. That for the other two classes, i. e., the curable and chronic, there 
should be a hospital for curable and a colony or institution for chronic 
cases. He did not believe in the absolute separation of the curable and 
incurable classes, but thought it preferable that they should be associated 
upon the same grounds though not necessarily in the same building. 

It is worthy of note that the general expression of opinion on 
the part of hospital superintendents then, as now, seemed to be 
that it was not wise to separate the acute from the chronic cases. 



IV. 

THE COLONY SYSTEM/ 

The Kalamazoo State Hospital is accredited with being the first 
institution of its kind in America to attempt the colonization of 
the chronic insane on farms. 

In 1885 a tract of 250 acres of productive land, situated about 
three miles north of the parent institution, was purchased for a 
dairy farm and a cottage was erected to accommodate about 45 
men patients, to be employed in looking after the herd and in 
raising general farm products. This addition to the institution 
was known as Brook Farm. 

This venture not only " fully met the immediate expectation 
of the officers and trustees by furnishing milk to the institution 
and occupation for the patients," but it also " suggested how other 
supplies and increased accommodations might be provided at a 
much reduced cost to the institution and to the state." 

In 1885 the trustees considered the further extension of the insti- 
tution by what they were pleased to term the colony system. The 
original plan contemplated the aquisition of a large tract of land 
in some farming community near the institution, the erection of 
suitable cottages, each with a capacity not exceeding 30 patients, 
a residence for the physician in charge, a chapel and an amuse- 
ment hall, and the necessary farm out-buildings. 

Pursuing this plan the trustees in 1887 and 1888 sought to 
enlarge the colony already started, but were unable to obtain land 
adjacent to Brook Farm. They, therefore, acquired a tract of 357 
acres 2^ miles southwest of the parent institution. Two hundred 
acres of this tract consisted of tillable, productive farming land, 
about 40 acres were of oak and hickory lumber, while the balance 
consisted of pasture land and lakes. The grove was so situated 
that it skirted the shores of and overlooked the lakes and formed a 
park to which the name Fair Oak was given. 

The hope of the originators of this plan was to obtain in one tract 
sufficient acreage for diversified farming, but a sufficient appro- 
priation could not be obtained from the Legislature. 

' By Herman Ostrander, M. D., assistant superintendent. 



THE COLONY SYSTEM I57 

The colony at present has one cottage accommodating 72 men 
patients, three attendants, five farm employees and one cook ; three 
cottages for women with a total capacity of 245 patients, one 
supervisor, 14 nurses, including night nurses, and three cooks ; one 
physician's residence, one large building containing a central heat- 
ing plant ; a general dining-room, easily converted into a dance and 
amusement hall; a laundry and sewing room, and a home for 
nurses. The buildings are lighted by electricity from a central 
power plant at the main institution. 

The colony has its own supply of water from drive wells, the 
pumps being operated by electricity, also supplied from the parent 
institution. The disposal of sewerage is by the intermittent sub- 
surface system. The institution has complete control of the lakes 
on the colony property and they are kept well stocked with fish. 

Boating and fishing afford recreation for the patients. 

The farm supports a large herd of cattle for dairy purposes and 
for beef. It also supplies the colony and to a considerable extent 
the main institution with vegetables. The farm work is done 
entirely by the patients under the supervision of the farm super- 
visor. The women are employed in housekeeping and in caring 
for the lawn and flower beds. They do all of the laundry work 
for the colony as well as their personal laundry, make most of 
their own clothing, and in the proper season pick all the small 
fruits and vegetables. There are also large classes in basketry, 
plain and fancy sewing and embroidery under the instruction of 
the industrial teacher. 

In correspondence with various public institutions in the United 
States and Canada, I have had nearly 100 replies to letters of 
inquiry concerning the extent of the colony system. These replies 
show that in 1912 farm colonies were in operation, either indepen- 
dently or in conjunction with the parent plant, in Alabama, Con- 
necticut, Georgia, Illinois, Iowa, Idaho, Kansas, Louisiana, Massa- 
chusetts, Alinnesota, New York, Ohio, Oregon, Pennsylvania, 
Utah, Virginia and Washington, as well as in the provinces of 
British Columbia, New Brunswick and Ontario. 

The State of Massachusetts has seemed to be the most active 
in extending this svstem. 



158 INSTITUTIONAL CARE OF THE INSANE 

The ( lardner State Colony, at Gardner, Mass., is located on a 
tract of 1650 acres of land and has 670 patients/ 

Another large colony of 600 patients is connected with the 
Worcester State Asylum. It is located on a tract of 900 acres, situ- 
ated some eight miles from the main institution, on the line of the 
Boston and Albany Railroad. The patients are cared for in 
detached buildings. These buildings are grouped with reference 
to economy in maintenance and administration. The men are 
engaged in the diiTerent farming operations, such as digging, 
trenching, road making, etc. 

Dr. E. V. Scribner, superintendent of this institution, mentions 
in his letter a somewhat interesting departure in furnishing out- 
of-doors occupation for incorrigible, refractory women patients. 
To quote his words : 

I at first set this women's crew at taking care of the grounds, tending 
flower beds and doing the lighter operations of farming. While I was 
looking around for further useful occupations they solved the question 
for me by voluntarily taking up the work of excavating and filling in 
around our buildings and doing a great variety of the work that the men 
had formerly done. I am now of the opinion that wherever there is work 
for the men there is work for the women. 

Other small colonies are operated in connection with the state 
hospitals at Taunton, Danvers, Monson, Medfield, Foxborough 
and Westborough. 

Ohio has a small colony connected with the Massillon State 
Hospital. 

The Oregon State Hospital has a colony of 300 patients five 
miles from the main institution. 

Minnesota maintains two state asylums for the chronic insane 
on the cottage plan, where farming is the chief occupation. One 
of these is at Hastings and another at Anoka. One of them is 
set apart for male patients and the other for female patients. 

There are several small colonies connected with the various 
New York hospitals, the largest one being a part of the Hudson 
River Hospital. It is especially interesting and noteworthy that 
there are summer or vacation camps connected with the Buffalo '' 

' See Gardner State Colony. 

^ The Buffalo Camp at Wilson, on Lake Ontario, has been given up be- 
cause of the change of ownership of the property. — Ed. 



THE COLONY SYSTEM 159 

and Rochester state hospitals, located on the banks of Lake 
Ontario, and one on the Susquehanna River, operated by the 
Binghamton State Hospital. 

The last Legislature of Kansas authorized the building of a 
new hospital for the insane on the colony plan. 

The Clarinda State Hospital, of Iowa, has a colony of 50 
patients on a farm of 307 acres named Willowdale, one and one- 
half miles from the main building. 

The East Louisiana Hospital maintains a colony of 80 patients, 
all males, on a tract of go acres. It contemplates erecting three 
buildings in the near future. The Central State Hospital at 
Petersburg, Va., has a farm colony known as Ashleigh Grange, 
which is practically self-supporting, and also one known as Nor- 
bunie, used exclusively for tuberculosis patients. 

The Georgia State Sanitarium maintains a colony of 100 negroes 
on a farm of 600 acres. This colony not only pays its own 
expenses, but contributes considerably to the support of the main 
institution. 

The largest colony in Canada is connected with the New West- 
minster Hospital, British Columbia. It is five and one-half miles 
from the main institution on a tract of 1000 acres, 600 of which 
have been cleared by the patients' labor since 1907. When com- 
pleted this colony will accommodate about 560 patients. The 
institution obtains from this farm all its milk, part of its butter and 
all of its vegetables. 

Other institutions mentioned are " trying out "' the plan on a 
smaller scale with satisfactory results. Since the beginning of the 
nineteenth century there has been a growing tendency toward the 
segregation of the insane by breaking away from the corridor or 
block plan of construction and adopting a system which will better 
subserve the purpose of economy and proper classification, in order 
to promote their improvement and comfort. The colony, the cot- 
tage and the boarding-out systems are but different methods of 
seeking the same results. Scotland has extensively employed the 
boarding-out system and in 1900 about 23 per cent of her insane 
patients were cared for in this way. The chief advantage in this 
system is economy in maintenance and greater contentment of the 
patient. Experience seems to have demonstrated that patients 
once established in homes had no desire to return to asylum life. 



l6o INSTITUTIONAL CARE OF THE INSANE 

To my mind the most valid objection offered to the plan is one that 
should condemn the whole system, namely, that constant associa- 
tion with the insane has a demoralizing effect upon the sane, espe- 
cially the young ; and the protection of society is of as great impor- 
tance as the care of the insane. 

The grouping of cottages about a main building has the objec- 
tion that it is difficult or impossible by ihis plan to eliminate insti- 
tutional features. 

The colony plan is too old to be considered an experiment. It 
is steadily growing in favor in foreign countries and in America. 
At Alt Scherbitz, near Leipzig, is an institution which has been 
conducted entirely on the colony plan since 1867. Kraepelin in 
1899 said: 

The construction of asylums has experienced extraordinary progress of 
late years by the evolution of so-called farm colonies in which patients 
are, as far as possible, given liberty and occupation in country pursuits. 
The whole question of the care of the insane for a long time has probably 
found its solution in this best and relatively cheapest method of support. 

Personal experience with the method, very imperfectly elabor- 
ated, and extending over a period of nine or ten years, has con- 
vinced me that it is the best plan yet devised for the treatment and 
care of at least 60 per cent of our insane for the following reasons : 

Of all the therapeutic means at our command in the treatment 
of the insane, suitable occupation is entitled to the first place. By 
suitable occupation I mean work and healthful surroundings, pref- 
erably in the open air, so directed and prescribed as to meet the 
individual needs of each case. The aggregation of a large number 
of persons in one building tends to the specialization of labor, 
which is not conducive to the complete development of the individ- 
ual. The work is done automatically and furnishes no incentive 
to mental stimulus. The individual is lost sight of. The main 
object is to get the work done. The colony system provides each 
individual with a great diversity of occupation of such a character 
as to stimulate and to bring into healthy action all mental faculties. 
The intelligence with which many colony patients assume and per- 
form responsible duties is extremely interesting. In getting statis- 
tics for a paper on this subject, published in 1900 in the American 
Journal of Insanity, I found that of the male population at the 
Kalamazoo State Hospital by a very conservative estimate 30 per 



THE COLONY SYSTEM l6l 

cent were able to work and could be trusted in open door cottages ; 
17 per cent of these, or 5 per cent of the total male population, 
were capable of planning work and directing the labor of others 
and keeping records, etc., in fact of doing any kind of work that 
was required of attendants who had charge of them; 15 per cent 
could work well and intelligently under the direction of other 
patients and the balance required closer supervision. These facts 
suggest that 25 to 30 per cent of our entire population is capable, 
under the direction of a physician and general supervisor, of suc- 
cessfully conducting a farm colony with no other supervision 
whatever. 

The colony plan is more economical if properly conducted. 
Food may be served in greater variety and with less waste and less 
per capita expense than where large numbers are massed together 
and fed from the common kitchen. This is not mere theory or 
guesswork. I have demonstrated it by actual experience and 
figures. Furthermore, with diversified and intensive farming, 
scientifically planned and carried on, labor becomes more remu- 
nerative than in the usual pursuits at large institutions. There is 
always a ready market in the institution itself for everything that 
is raised on the farm. 

The utility of the colony system is not limited to quiet, able- 
bodied, trustworthy patients as is generally supposed. Experience 
has demonstrated that farm work and out-of-door pursuits are as 
well adapted to the disturbed as to the quiet class. The colony 
system affords a rational plan for the treatment of able-bodied 
insane epileptics. Their removal from the wards relieves other 
patients from a great source of distress and the colony plan affords 
the best facilities for proper diet and the regimen so essential in 
treating this class of patients. 

It is not feasible or economical to operate a colony at a great 
distance from the parent institution. For this reason colonies in 
connection with many of our American institutions are often 
impracticable. Either land near them is not available or is avail- 
able at so high a price that the economical features of the plan 
are destroyed. Preferably the whole institution should be located 
on a single large tract of land, consisting of not less than one acre 
to each patient. It is impracticable to operate a colony at a greater 
distance than three miles from the parent institution. 



l62 IXSTITUTIONAL CARE OF THE INSANE 

The colony system is practicable ; it is capable of a much higher 
degree of development, and it meets the needs of a much greater 
percentage of cases than was formerly supposed. 

The ideal institution for the insane should have a hospital for 
acute curable cases, an infirmary with special equipment and 
trained nurses for the care of the sick and helpless, and a farm 
colony with homelike cottages and surroundings, where all the 
healthy, able-bodied chronic cases, including the refractory ones, 
may be trained in pursuits that are healthy, educative to the 
patient and remunerative to the institution. 



V. 
STATE CARE. 

State care is now definitely understood to be the care of the 
dependent insane exercised by the state as state charges, not in 
any way under the care and management of county or town 
officials. Formerly state provision, generally speaking, meant a 
state institution established and built by the state and managed by 
state officials, whose expenses were paid by taxpayers or by indi- 
viduals. Thus, for example, the Williamsburg State Hospital in 
Virginia, when built by the state in 1773, was placed in the hands 
of a so-called Court of Directors, who were absolutely in charge 
of it and who managed it as an independent, self-perpetuating cor- 
poration. The same state of things existed at the present South 
Carolina State Hospital at Columbia, S. C. It was supported by 
those who sent patients to it, whether counties or individuals, until 
about 1872, and was not a state-controlled institution, according 
to the present understanding of the term, until after that date. 

Similar conditions were present at Utica, N. Y., where private 
patients were received at the expense of their friends, relatives or 
guardians and indigent persons were received at the expense of the 
counties in which they had a legal residence. In other states, as 
in Michigan, whose first institution was modelled almost wholly 
upon that at Utica, N. Y., state care was carried out along the 
same lines. In short, the insane were regarded as wards of the 
county and were supported in the state institution by different 
counties, to whose treasurers bills were rendered quarterly for the 
support of all indigent patients. 

At present, the phrase state care does not mean a state aided 
institution or an institution for the care of acute or chronic cases, 
but the care of all the insane in the state, in institutions main- 
tained by the state under the management of state officers and 
appointees. There is an important difiference between state care 
as thus understood and state support for a limited number of 
insane in a state hospital, with the majority of the dependent 
insane in county almshouses. 



164 INSTITUTIONAL CARE OF THE INSANE 

The advantages of state care, as it is now understood, are obvi- 
ous, since the welfare and well-being- of the patients become the 
first consideration, as the only object to be sought by institutional 
treatment. Under county care there was danger of as many meth- 
ods of care and of devices for economy as there were institutions. 
Broad, comprehensive plans for the betterment of the insane, their 
care and their cure were impossible as long as the custody of 
patients was placed in the hands of inexperienced persons, like 
county commissioners or boards of supervisors, or overseers of 
the poor. These men, as a rule, had an eye single to the taxpayer, 
and to the possibility of achieving a local reputation for economy. 
Moreover, in many instances, an opportunity for minor patronage 
was thus afforded to county officials, by which their political pros- 
pects might be increased and their personal importance to their 
communities enhanced. It is unwise to give men of this type the 
responsibility of determining whether or not a patient shall be sent 
to a state institution or retained at home in a county establishment, 
whose sole advantage is a greater economy, and the unwisdom of 
this course became apparent when an attempt was made to do 
away with county institutions. They possessed an influence which 
extended throughout every portion of the state ; and it proved a 
difficult task to eradicate the mistaken idea that economy was the 
prime consideration in the care of the insane and irresponsible. 

The experience of the hospital at Utica demonstrated the futility 
of the original idea that a single institution in a central part of the 
state was sufficient to care for all its insane, because in practical 
operation county institutions and receptacles in connection with 
almshouses (where the insane were neglected to a degree which 
almost staggers the imagination) were invariably established to 
receive chronic patients removed from the central hospital to make 
room for cases of recent disease, which were presumably curable. 
The deplorable history of the original attempt to found a single 
small institution for the care of the insane of the whole state is yet 
to be written. There is no more sorrowful chapter in the history 
of mistaken philanthropy than that furnished by the experience of 
New York and other states where this idea prevailed. 

The first effort to build a state institution was at Williamsburg, 
Ya. This was erected not for the dependent insane alone, but for 
all classes. The second attempt was at Columbia, S. C, and here 



STATE CARE I 65 

also both pay and indigent patients were received, the latter for 
about 40 years at the expense of the counties in which they resided. 

The first state institution exclusively for the pauper insane was 
at Worcester, Mass. It was built by the state for the care of the 
dependent insane and placed under the charge of Dr. Woodward, 
who had been formerly connected with the Hartford Retreat. 

The next state institution in point of time seems to have been 
that now known as the Utica State Hospital, opened in 1843, which 
has probably had a greater influence upon the erection of other 
state institutions than any other single establishment. As has been 
previously stated, at Utica the state seemed to be simply a land- 
lord or manager acting for the benefit of counties and individuals, 
who paid alike for the support of patients. In Ohio the hospitals 
originally established at Columbus and Cleveland were more 
nearly state institutions, as they were built by the state and sup- 
ported by it, all patients being admitted at the expense of the state, 
whether indigent or otherwise. The same conditions obtained in 
Indiana and Illinois. In these states the rights of each county were 
recognized, a statute being enacted to establish what was known 
as a county quota for patients. Fresh cases, however deserving, 
could not be received from any given county if its quota happened 
to be filled, nor could a county which had no insane give its quota 
to any county which needed to secure immediate treatment for 
acute cases. 

Recently, nearly all the newer institutions for the insane in the 
United States have been established as state institutions. They 
have not, however, been able to render what we term to-day state 
care, because they have been inadequate to receive even the acute 
insane for long. Room for acute and presumably more hopeful 
patients could only be secured by removing those who had become 
chronic patients to the county house or receptacle. If any chronic 
patients were retained by the state, there was generally a strong 
feeling among those whose friends had been excluded that favor- 
itism had been shown. In New York at one time the period during 
which a cure was supposed to be effected was 13 months and all 
persons who had been in the institution during such a period of 
time could be removed to make room for other patients. In many 
instances, however, such removals did not take place, as the friends 



l66 INSTITUTIONAL CARE OF THE INSANE 

of chronic patients were often influential and made appeals to 
boards of mana.^ers which could not well be refused. 

It is interesting to consider the conditions which eventually 
brought about the conviction in the public mind that state care as 
it is now understood was a necessity. 

The neglect and abuses in the care of the chronic insane, 
whether in almshouses, under the charge of county commissioners, 
or in towns under the charge of selectmen, as in New England, 
were found to be many and grievous. The lack of any definite 
scheme of care was apparent everywhere and the necessity of 
placing insane people in jails, or pens, or loathsome county recep- 
tacles became increasingly repugnant to the public mind, until at 
length the feeling that the state should take care of all of its insane, 
without regard to residence or to the opposition of local economists 
in the various counties, became irresistible. 

The rapid growth of new states like California and many of 
the Western states, which at first had no efficient county or town- 
ship organization, rendered it essential to establish institutions 
directly under the control of the state. This was especially true 
in those states to which the insane and the irresponsible had been 
attracted by mining, or lumbering, or similar primitive employ- 
ments, and communities found themselves overburdened by the 
insane without the slightest facilities for their care and manage- 
ment. 

In the older states it was found that county and township 
organizations often served their purposes inequitably in under- 
taking the care of the insane. In Massachusetts, for example, 
the towns which had lost their enterprising citizens, through emi- 
gration to newer sections of the country, were overwhelmingly 
burdened by a residual mass of chronic insanity in the state hos- 
pitals which, under the law, was still chargeable to the town. 
This condition finally became so serious that it could no longer be 
borne by impoverished and struggling hill towns or towns contain- 
ing many abandoned farms inhabited by aged, feeble and helpless 
people who were too old to become pioneers in newer and more 
prosperous regions. State care and state support for the relief 
of these communities were absolutely essential. 



state care i 67 

Development of State Care. 

The development of state care was slow and in every one of the 
older and more conservative states was attained only after severe 
struggle. In New Hampshire the act legalizing state care was 
passed only a few years ago and did not become operative until 
1913. In Maryland, although the act was passed a dozen years 
ago, full care has not yet been attained. In New York, after many 
attempts to meet the problem of the insane, first by the establish- 
ment of an institution for the chronic insane at Willard and Bing- 
hamton and later by new institutions at Middletown, Poughkeep- 
sie, Bufifalo and Ogdensburg, as well as by institutions for the 
criminal insane at Auburn, and later at Matteawan and Dannemora, 
the question of state care continued to be persistently agitated, and 
in 1895, after several abortive attempts, a bill was finally passed 
which established state care for all the insane of the state. This 
bill required the addition of several institutions and a division of 
the state into districts in order to provide for patients of the acute 
and chronic classes at home. The adoption of state care by the 
State of New York unquestionably gave great impetus to the 
movement, which has since spread to other states with comparative 
rapidity. 

The best development of state care is in New York. It is the 
only state where it is carried out without any reference to county 
hospitals. The state must provide for all cases of insanity wher- 
ever developing and jails and poorhouses cannot be used for the 
custody of the insane. 



VI. 
THE WISCONSIN SYSTEM OF COUNTY CARE. 

The so-called Wisconsin system of county care of the chronic 
insane, modified forms of which are in force in New Jersey and 
Pennsylvania, had its origin in a law passed by the Legislature of 
Wisconsin in 1881, it is said at the suggestion of Andrew E. 
Elmore, then president of the State Board of Charities, which pro- 
vided that, with the consent of the State Board of Charities and 
Reform,^ any county could purchase a site for an asylum for the 
chronic insane, and erect buildings thereon for their care, pursuant 
to plans, drawings and specifications approved by said board ; and 
levy taxes and issue bonds to defray the cost of such site and build- 
ings, and of furnishing and maintaining them. Asylums thus 
established were to be governed by a board of three trustees, one 
retiring each year, chosen by the Board of County Supervisors. 
They were to receive as compensation for their services $3 a day 
and mileage. No member of the Board of Supervisors was eligible 
for the position of asylum trustee. To such an asylum all inmates 
of state institutions for the insane committed from or belonging to 
the county and held as chronic or incurable, all insane inmates of 
the poorhouse, and all other persons belonging to or residing in 
the county, adjudged to be insane according to law and who might 
properly be confined in an asylum, could be transferred. Each 
county caring for its own chronic insane in an asylum was entitled 
to receive a stated sum per week for each person cared for. 

The Wisconsin system can hardly be regarded as one thought 
out from the beginning. Its origin seems to have been an accident 
that grew out of the exigencies and pressing necessities of the 
situation in existence when it was established.^ 

^ In 1891 the State Board of Charities and Reform and the State Board 
of Supervisors were merged into one body known as the State Board of 
Control, having all the powers and duties of the two other boards which it 
superseded. 

' Burr, C. B., M. D., " Visit to the Wisconsin County .Xsylums." American 
Journal of Insanity, Vol. 55, p. 286. 



THE WISCONSIN SYSTEM OF COUNTY CARE 169 

In 1875 the population of the state was 1,236,729; the estimated 
total number of insane, 1732; the number under care in the two 
state hospitals at Mendota and Winnebago was 651, leaving 1081, 
or over 62 per cent, uncared for/ 

Some provision was necessary to care for this constantly grow- 
ing class of unfortunates, other than that supplied by the jails 
and poorhouses of the various counties. Inasmuch as the cost of 
providing and maintaining hospitals under the control of the state, 
similar to those erected by other states, was large, the State of 
Wisconsin was unwilling to make further similar efforts in the 
direction of state care. 

In 1880 the Milwaukee County Hospital, which was designed to 
receive patients from that county only, was already established. 
This was what may be called a semi-state asylum, as both the state 
and Milwaukee County contributed to its support. It received 
both acute and chronic cases, and, in conjunction with the two 
state institutions already referred to, oflfered the only accommoda- 
tion to the insane of the state other than that provided by county 
almshouses, until the year 1881, when the law already referred to 
was enacted, and the State of Wisconsin became definitely com- 
mitted to the policy of a county care of its chronic insane. 

Under the law as amended, upon the completion of a county 
asylum and its approval by the State Board of Control, a certificate 
of that fact, signed by its president and secretary, being filed with 
the secretary, each county so caring for its chronic insane under 
rules prescribed by the board receives from the state $1.75 per 
week for each of its own patients, and $3.50 per week for patients 
belonging to other counties. 

The State Board of Control has authority, whenever in its 
opinion any county has not made provision for the proper care of 
its acute or chronic insane, to direct the removal of either class 
to the asylum of some other county possessing suitable accommo- 
dations for them ; the expense of such removal is borne by the 
county to which such persons belong ; and any county whose 
asylum can accommodate a larger number of chronic insane than 
are resident therein, may receive such insane persons as may be 
removed thereto under the direction of the State Board of Control. 

^ BuUard, Ernest L., M. D., " The Wisconsin System of County Care of 
the Chronic Insane." 
18 



170 INSTITUTIONAL CARE OF THE INSANE 

The county asylums created under the Act of 1881 are usually 
located on farms of over 300 acres, within a mile or so of a city or 
good-sized town. They are now 35 in number. The number of 
patients varies from 68 to 239, the average being about 150 
persons. 

The trustees exercise the powers usually vested in trustees of 
charitable institutions ; they appoint the physicians and the super- 
intendent. The character of the officers selected varies greatly 
according to the public sentiment of the locality ministered to. 
The county chronic asylum of Milwaukee, for example, employs a 
resident medical officer and an adequate number of day and night 
nurses. This cannot, however, be taken as evidence that the same 
or equal care is given in the average county asylum. The early 
asylums in fact were such in name only, the pauper and insane 
being cared for in one and the same county building. Even after 
17 years of trial the basis of care was thought by a competent 
observer to have continued much the same as that of the poor- 
house.' 

According to Dr. Richard Dewey,' " the boards governing the 
counties of the various states have a purely economic function." 
" Keeping the taxes down " is their chief and proper function, 
and the only charitable work that naturally comes to them is the 
care of the paupers. Insane paupers are apt to be regarded by 
them as only more unwelcome paupers than the others ; and, judg- 
ing from the measure of care generally meted out to them, less 
deserving. This is not saying that there are not exceptional insti- 
tutions under the care of the counties that are well managed, just 
as there are state institutions that are badly managed, but the rule 
is the other way, and must be from the nature of things. 

" Wisconsin has sought to overcome the disadvantages of county 
care, and the check upon the parsimony and ignorance of the 
counties has been in part successful, but something more is needed. 
No one will deny that enlightened benevolence and special experi- 
ence are needed by any man, or any body of men, who take charge 
of the insane." 

' Burr, C. B., M. D., " Visit to the Wisconsin County Asylums." Journal 
of Insanity, Vol. 55, 1898. 

* " County Asylums for the Chronic Insane," read at the i8th meeting of 
the Wisconsin State Medical Society. 



THE WISCONSIN SYSTEM OF COUNTY CARE I7I 

According to Dr. Ernest L. Bullard, in the article already quoted, 
" although the county, through its appointed trustees, has primarily 
full charge of and is left unhampered in the administration of the 
ordinary affairs of the asylum, the state, through the agency of the 
Board of Control, has all needful authority to enforce its orders 
in the following particulars : 

1. The consent of this board must be obtained before a county may issue 
bonds or levy taxes for the erection of an asylum. 

2. No building operations can be begun until the plans have been 
approved, and no patient can be received until the buildings have been 
accepted by the board. 

3. No county can receive its per capita allowance from the state until 
its bills have been approved by the board. 

4. If, in the judgment of the Board of Control, a county is not making 
proper provision for its insane, it has authority to remove every patient 
to other asylums where better conditions prevail. 

Dr. Bullard states that he knows of but one instance of a serious 
and long-continued disagreement between the state and local 
boards. This can mean one of two things ; either the standard of 
county care is, in practically every instance, equal to that demanded 
by the State Board of Control, or that the State Board of Control 
is disposed to allow a latitude in its requirements, depending upon 
the sentiment of the communities supporting the asylums. That 
there can be practical and efficient supervision by a state board far 
removed from an institution is doubtful, especially when such a 
board is made responsible for the administration and supervision 
of all the state institutions. The very number of these asylums 
precludes any chance of very diligent supervision by the State 
Board, and certainly in the majority of instances the sentiment of 
the community of location must be the deciding factor in the qual- 
ity of care given. Local standards of care will inevitably obtain in 
spite of central supervision. 

The asylums, with the exception of the Milwaukee County Asy- 
lum, at Wauwaiosa, which has a medical superintendent, are in 
charge of laymen as superintendents. There is also a matron, fre- 
quently the superintendent's wife ; their combined salaries amount 
to from $2000 to $2500 a year. There is a visiting physician, 
whose average pay is $350 per year. 



172 INSTITUTIONAL CARE OF THE INSANE 

The State Board of Control on April 5, 1900, issued instructions 
that : 

Asylum physicians should not be selected and contracts for the medical 
care of the insane awarded upon competitive bids ; the trustees should 
appoint some competent physician and fix his salary. The selection should 
be made with the care and consideration that might reasonably be expected 
in the selection of a family physician. 

The physician is supposed to make visits twice each week and 
attend to a large number of medical details, the sanitary condition, 
the health, diet, clothing, cleanliness of the patients, the amount of 
work required of them, etc., but he possesses no authority. All 
the physician can do is to advise, and his recommendations may 
or may not be carried out. 

In a majority of the older asylums bathing and sanitary facilities 
are inadequate, to say the least. In practically all of the asylums 
facilities and arrangements for suitable classification are lacking. 

In the county asylums it is claimed that 30 per cent of the patients 
work all day ; 20 per cent work one-half day or more ; and 23 per 
cent do some work. Inasmuch as the range of occupation is prac- 
tically confined to farm and household work it is difficult to see 
how the patients manage to occupy themselves during the winter 
months, since employment in other industries is practically un- 
known. No efforts are made in the direction of entertainments, 
except in a few of the more enlightened institutions, where weekly 
dances are held. There is also practically little effort at ornamen- 
tation of grounds and buildings, the ideas of those in charge seem- 
ing to be developed along strictly utilitarian lines. 

For the 100 to 200 patients generally cared for in these institu- 
tions, there are provided about four attendants, and as a rule two 
night nurses. Patients are left alone much of the time, it not being 
the aim of the system to give patients constant supervision. In a 
majority of the cases patients receive night attention from nurses 
of their own sex. 

Dr. E. L. Bullard states that among the features to be com- 
mended in these relatively small county asylums are : 

1. Greater personal freedom. 

2. A nearer approach to the home life of the patients. 

3. The excellence and abundance of the food. 

4. The greatly reduced cost of maintenance. 



THE WISCONSIN SYSTEM OF COUNTY CARE 1 73 

As the bookkeeping methods in vogue in the different county 
asylums vary greatly, the statistics of the per capita cost of caring 
for the inmates possess but little value. The per capita cost is, 
however, unquestionably lower than it is in the larger state insti- 
tutions of Wisconsin and elsewhere ; this question of " cheapness " 
being one of the strongest arguments of the partisans of the 
system. 

A prime objection to such a form of care of the chronic insane, 
to say nothing of acute cases of insanity, is that its standard is 
established by the requirements of other inmates of the almshouse 
and is custodial rather than hospital in character. It varies accord- 
ing to the traditions of the place and the personality of the superin- 
tendent and does not possess any uniform or settled principles. 
There may be as many systems of care as there are asylums. The 
central unifying principle is economy and not the requirements of 
persons who are afflicted with a chronic mental disorder. The 
majority of the superintendents are very generally men who are 
interested in the work of the farm, and are anxious to make a good 
financial showing. The superintendent may be kind and consider- 
ate of his charges, especially of those who, through physical or 
mental disability, ought not to attempt severe physical labor, or he 
may be a forceful, energetic driver who desires to attain results 
and may sacrifice the permanent good of his patients. 

It is evident that the tendency of the system is to convert the 
state hospital into an institution for the custodial care of the untidy, 
violent, turbulent and uncomfortable patient of the chronic class 
who cannot be kept in a county asylum without increased expense 
and trouble and to cease to use it for the medical treatment of 
acute and hopeful cases. All are familiar with the fact that local 
institutions for the custody of the insane always attract to them- 
selves early and presumably curable cases especially of the quieter 
sort, whose relatives may shrink from sending them a long distance 
from home and who are hopeful that the mental aberration may 
prove to be temporary. Under such circumstances the hopes of 
recovery of such patients may be destroyed by the delay. If state 
hospitals could be used for the curative treatment of patients 
exclusively or largely and the county institutions were utilized for 
chronic cases exclusively of every class, the evil would not be so 
great, although it is probable that the expenses of the county asy- 



174 INSTITUTIONAL CARE OF THE INSANE 

lum would be materially increased. It has been asserted in fact 
by those who are familiar with the situation that many of them 
are now maintained upon a scale of too ^reat economy and that 
the sum received from the state is more than sufficient to pay all 
the expenses of the asylums. 

According to Dr. D. Hack Tuke/ who was disposed to regard 
the scheme with favor: 

It is very clear that the success of the system requires constant care 
in the selection of cases, so as not to place in these small county asylums, 
where there is no resident doctor, acute and curable cases requiring con- 
stant medical care. I believe that, among the chronic insane, there is, as 
a matter of fact, very little selection of cases, probably too little. The 
superintendents of the state hospitals furnish the lists of chronic insane 
which are to be returned to the counties. They will, of course, retain the 
best cases, and sometimes send unsuitable ones to the county asylums. 
Occasionally the counties return a homicidal or filthy patient. Otherwise 
they have so far taken all the chronic cases from their own counties, who 
usually are the worst treated, and therefore, probably, the worst behaved, 
insane inmates of almshouses. 

The appointment of similar able and well-intentioned men on the Board 
of Charities, as well as of thoroughly reliable masters, is also essential to 
success. Otherwise there will inevitably be a return of the evils from which 
the insane in the old almshouses have escaped. 

The objections to the system have been stated by Dr. C. B. Burr/ 
as follows: 

1. Absence of the hospital idea. 

2. Lack of medical oversight. 

3. The inadequate care of patients, particularly of the filthy and feeble 
classes and epileptics. 

4. Lack of sufficient attendants, which necessitates patients remaining too 
much indoors, particularly in the winter time. 

5. Lack of standards of care prescribed and enforced by central authority, 
superior to politics, as shown in the extreme variation in per capita cost and 
differences in beds, furnishings, attendance, etc. 

6. Lack of efficient state supervision. 

7. Frequent lack of discriminating local supervision, this due chiefly to 
absence of knowledge of the requirements of the insane and the desire to 
make favorable financial showings to boards of supervisors. 

* The Insane in the United States and Canada, London, 1885, p. 88. 
'"'A Visit to the Wisconsin County Asylums," American Journal of 
Insanity, Vol. 55. 



THE WISCONSIN SYSTEM OF COUNTY CARE I75 

On June 30, 1912, the total insane population of Wisconsin was 
6855, of which number, 5016 were in the county asylums. 

In a subsequent volume, in a chapter dealing with the care of 
the insane in Wisconsin, copious extracts have been given from a 
paper by Ernest L. Bullard, M. D., several times quoted in these 
pages on " The Wisconsin Care of the Chronic." 



CHAPTER V 

GOVERNMENT AND MANAGEMENT OF HOSPITALS 
ARCHITECTURE 



I. 

EVOLUTION OF THE ADMINISTRATION OF 
HOSPITALS. 

The first managing boards of hospitals for the insane had a 
variety of titles. In Virginia they received the rather formidable 
designation of Court of Directors ; in Maryland and the District of 
Columbia they were called Visitors, and in New York Managers, 
while in most of the states they were denominated Trustees. In 
corporate institutions they were, in theory, a committee represent- 
ing the subscribers and were charged with the immediate manage- 
ment of the affairs of the institution. In state institutions they 
acted as representatives of the commonwealth. They were, as a 
rule, selected by the Governor from among the best citizens, being 
chosen, not for their philanthropy alone, but for their business 
ability and experience in affairs. They received no pay other than 
their necessary expenses in the discharge of their oflficial duties, 
because their service to the state was so valuable it was manifestly 
impossible to reward it by any adequate salary. It was also feared 
that if a nominal salary, however small, should attach to the posi- 
tion of manager, such salary would attract men of less desirable 
character to become applicants for appointment. It is most credit- 
able to the high-minded philanthropy of the public-spirited men 
who thus served the public to recall that they gave gratuitously to 
the state a grade of service which could not be paid for. In some 
cases they spent many days each year in supervising the work of 
the institution committed to their care. In the early history of the 
Friends' Asylum at Frankford a dissatisfied patient on his dis- 
charge after his recovery from an attack of melancholia sued the 
directors of the asylum and recovered $15,000 as damages, which 
sum was paid out of the private funds of one or more of the 
directors and not out of the asylum treasury. 

At the \"ermont Asylum at Brattleboro, now known as the Brat- 
tleboro Retreat, the trustees gave most valuable personal service 
to the institution ; they selected and bargained for lands in a rural 
community, made estimates for buildings, drew contracts and 
looked after all details of building as carefully as in any private 



l80 INSTITUTIONAL CARE OF THE INSANE 

business, althoug:h forbidden to receive any salary by the terms of 
the will under which they had been appointed. 

Gradually, however, as institutions grew older, it became more 
and more convenient to entrust the whole management to an able 
superintendent. In this manner were developed men Hke Wyman, 
Kirkbride, Ray, Earle, Brigham, Gray, Bancroft and others. This 
development of strong men, who were willing to assume responsi- 
bility, was advantageous in certain ways because each institution 
thus secured the initiative of a forceful, self-sacrificing and 
enthusiastic personality. This explains in some measure the tone 
of " extreme philanthropy " which has been said to characterize 
the early reports. They were written by men of devoted char- 
acter who, like Miss Dix, were persuaded that the care of the 
insane was a sacred calling which required the best energies of 
their minds and hearts. They undertook the task of arousing indif- 
ferent or hostile communities and commonwealths to action in a 
spirit of the purest philanthropy. The disinterested zeal of these 
able men was an important agent in bringing about the earlier pro- 
vision for the neglected insane in many states. 

After the first glow of enthusiastic effort in behalf of the insane 
had passed and the control of institutions had come to be regarded 
as one of the perquisites of a dominant political party, there 
developed some hitherto unsuspected disadvantages in this method 
of government. Local influences displayed in the matter of pur- 
chases, in the deposit of the money belonging to the institution in 
local banks, in local pressure for the employment of residents of 
the immediate vicinity who happened to belong to the political 
party then dominant, all began to make themselves felt. These, in 
turn, influenced the type of men selected to occupy the position of 
superintendent. 

This political trend finally resulted in the decline of the system 
and the substitution, first, of paid boards and ultimately, in many 
states, of boards of control. Paid boards were instituted because 
political appointees often felt that their services must be rewarded 
by something more substantial than a purely honorary appoint- 
ment. To furnish a suitable salary for each member of a large 
board seemed an extravagance to rural legislators and boards were 
consequently decreased in size before salaries were attached to 
membership in them. The units in the divisor being diminished, 



EVOLUTION OF THE ADMINISTRATION OF HOSPITALS l8l 

the resulting quotient of salary for the fortunate men who re- 
ceived appointment became greater. In order to increase the 
salaries paid to such boards, politicians conceived the happy- 
thought of reducing their number and concentrating the control 
of institutions in a single board. The next step was an easy one, 
viz. : to concentrate the government of all the charitable institu- 
tions of a state in a single board which should make a business of 
charitable administration. Hence hospitals for the insane and 
institutions for the feeble-minded, schools for deaf and blind, 
orphan asylums, reform schools, penitentiaries, and, in one state, 
normal schools and universities, were all placed under a single 
board. The favorite number for membership has generally been 
five persons, although several excellent boards of control have 
contained but three members. 

In certain states a similar effort to do away with boards of 
trustees or managers resulted in the establishment of institutional 
control by a lunacy commission. At first boards of state charities 
performed the duty of inspection, sometimes as a body or through 
a committee, but more generally through a secretary. Control was 
thus sometimes exercised in the matter of appropriations. Almost 
every state provided that when appropriations were desired they 
should be approved by the Board of State Charities, after an 
inspection of the institution and full consideration of its needs. 
The Board of Charities in too many instances found its recommen- 
dation disregarded by the Legislature charged with the responsi- 
bility of appropriating or withholding money. Frequently appro- 
priations were made which were frowned upon by the Board of 
Charities or else appropriations which were considered essential to 
the welfare of the institution were not made. Moreover, there 
grew up the feeling that too much labor devolved upon the boards 
of state charities, so that in New York, Massachusetts and, to a 
limited extent, in Pennsylvania their duties were finally limited to 
the inspection of almshouses and jails, asylums for children, insti- 
tutions for the feeble-minded, county receptacles for the insane, 
and the soldiers' homes. The duty of inspecting state institutions 
for the insane was assigned to a Board of Insanity, as in Massa- 
chusetts ; to a Commissioner in Lunacy, as at first in New York, 
or to a Committee in Lunacy, as in Pennsylvania. The first 
Commissioner in Lunacy in New York, appointed as a result of 



l82 INSTITUTIONAL CARE OF THE INSANE 

the provisions of the law of 1873, was Dr. John Ordronaux. He 
was succeeded by Dr. Stephen Smith, who in turn was succeeded 
by Dr. Wesley Smith. These men did excellent service, but their 
functions were confined to inspection and advice, and, with the 
advent of state care, it became apparent that a single commissioner 
would not be adequate to discharge the increasing duties required 
by the state hospitals. Recourse was consequently had to legisla- 
tion through which the Lunacy Commission was enlarged by the 
addition of two members to the physician who had previously been 
the sole commission. The act provided that one of the additional 
commissioners should be a lawyer and the third a good business 
man of large experience. It soon became evident to the Commis- 
sioners in Lunacy that additional executive powers were needed to 
render the commission equal to the task imposed upon it. This idea 
met with much opposition at first, but eventually the views of 
the Lunacy Commission prevailed, the boards of managers were 
abolished, and boards of visitors were appointed for the different 
hospitals of the state. The Lunacy Commission was given ample 
powers to supervise every portion of the hospitals, to purchase sup- 
plies, to appoint and remove superintendents, and to control all 
details of administration. The effect of this centralization of 
power has been variously regarded, but there is good reason to 
believe that, upon the whole, it has made for a more uniform care 
of patients, better methods of treatment, and increased facilities 
for scientific and laboratory work. It is of interest to observe that 
during the past year in New York the pendulum has begun to 
swing in the opposite direction. Boards of managers have been 
re-installed and the importance and multifarious functions of the 
Lunacy Commission have been, to some extent, curtailed.' Boards 
of control of institutions for the insane have been established in 
many Western states, the most successful being those of Iowa and 
Minnesota. 

' The Lunacy Commission in 1914 was re-named a Hospital Commission 
and its three members were given an equal rank, so that the physician- 
member had no longer the presidency or any preponderance in salary or 
influence. 



II. 

PRESENT GOVERNMENT OF INSTITUTIONS FOR 
THE INSANE. 

A careful analysis of the methods of government of institutions 
throughout the United States indicates certain differences in the 
modes of control which have developed in the newer states or have 
been developed elsewhere from older methods. 

It is evident that the early system of control in institutions for 
the insane was derived largely from the experience of institutions 
in England, where, in many cases, a board of trustees, or directors, 
managers, or governors was selected by the annual subscribers to 
the funds of the institution. The contributors were in the habit of 
electing representatives to manage the institution and social and 
other influences probably combined to create a large board. Thus, 
for example, there might be life members and life patrons who 
had made large subscriptions and consequently were entitled to be 
represented upon the board of control in equity or honor. The 
size of the board thus created rendered it impossible for the direc- 
tors to meet as a body to manage the affairs of the institution and it 
became customary to delegate the management to an executive 
committee, small in numbers and better fitted for executive work. 

When the Virginia State Hospital at Williamsburg was built and 
organized in 1773 a court of directors consisting of twelve mem- 
bers was appointed to manage its affairs and given certain judicial 
powers. In Philadelphia, in connection with the Pennsylvania 
Hospital, a board of managers was selected from the annual sub- 
scribers, which acted through an executive committee. The same 
was true of the New York Hospital in New York, with its branch, 
the Bloomingdale Asylum, which was managed by a committee of 
the governors of the New York Hospital. Similarly the McLean 
Asylum at Somerville, a branch of the Massachusetts General 
Hospital, was under the control of a committee of the board of 
directors of that hospital. When the Hartford Retreat was estab- 
lished a comparatively large board of directors was appointed in 
accordance with previous custom, which transacted the business 



184 INSTITUTIONAL CARE OF THE INSANE 

of the institution throui^h an executive committee. The same was 
true of the Friends' Asylum at Frankford, founded in 181 7. It is 
apparent that when the state institutions for the insane were estab- 
lished it was but natural to appoint boards of trustees, directors or 
managers through the central authority of the state, viz., the 
Governor. For many years this was the form of government 
adopted for state institutions in nearly all of the United States. 

An analysis of different institutions shows that the state insti- 
tutions in Alabama, Arkansas, California, Connecticut, Delaware, 
District of Columbia, Georgia, Idaho, Indiana, Louisiana, Maine, 
Maryland, Massachusetts, Michigan, Mississippi, Missouri, Ne- 
braska, New Hampshire, New Jersey, New Mexico, New York, 
North Carolina, North Dakota, Oklahoma, Pennsylvania, South 
Carolina, Tennessee, Texas, Vermont and Virginia are still all 
under boards variously named governors, managers, visitors, direc- 
tors or trustees, appointed as a rule by the Governor, and responsi- 
ble for the management and control of one or more institutions. 

The composition of the boards varies considerably in numbers 
and somewhat in powers, thus : 

In Alabama a board of seven trustees, serving for seven years, 
fills its own vacancies and the nominations made by it are con- 
firmed by the Senate. This board elects the superintendent for a 
term of eight years and may remove him for just cause. 

In Arkansas for the management of the state institution there 
is a board of six trustees, appointed biennially by the Governor, 
one from each Congressional district. This board elects a superin- 
tendent for a term of four years. 

In California there is a board of managers appointed for four 
years by the Governor for each institution. Each board appoints 
the superintendent, subject to an examination by the General 
Superintendent of the Hospitals for the Insane, who is a state 
officer. 

In Connecticut a board of twelve trustees is appointed by the 
Senate, which, with the Governor as an ex-oMcio member, controls 
each hospital. This board appoints and removes all officers and 
fixes their compensation. 

In Delaware a board of nine trustees, three from each county, is 
appointed by the Governor, to serve for three years. This board 
appoints all officers. 



PRESENT GOVERNMENT OF INSTITUTIONS 185 

In the District of Columbia a board of nine visitors is appointed 
by the President. This board serves practically for life and has 
the supervision of the afifairs of the institution, but exercises little 
more than supervisory control. The superintendent of the hospital 
is appointed by the Secretary of the Interior. 

In Georgia the State Sanitarium is under the control of a board 
of ten trustees, appointed biennially by the Governor, which elects 
the superintendent and other ofificers and may remove them for 
cause. 

In Idaho a board of three directors is appointed for each hos- 
pital, one hospital being- served for two years and the other for 
three years. Each board elects a superintendent to hold office dur- 
ing its pleasure. 

In Indiana there is a board of four salaried trustees for each 
hospital, appointed for four years and removable for cause upon 
written charges. Each board appoints a superintendent. 

In Louisiana a board of eight administrators for each hospital 
is appointed for a term of four years by the Governor, who is also 
an ex-officio member of each board. The board of administrators 
elects the superintendent. 

In Maine there is a single board of seven trustees, one of which 
must be a woman, for the management of both hospitals. This 
board is appointed by the Governor, with the advice and consent of 
the council, and holds office during the pleasure of the Governor 
and council for not more than three years. The board appoints 
the superintendent of each of the two hospitals. 

In Maryland each hospital is controlled by a board of nine 
managers, appointed by the Governor for six years. Each board 
appoints a superintendent and other officers and has power to 
remove them for cause. 

In Massachusetts each hospital is governed by a board of 
trustees, consisting of five men and two women, with the exception 
of a single board, which is composed only of seven men. These 
trustees are appointed by the Governor for a period of seven years. 
The trustees appoint the superintendent and other officers. 

In Michigan each hospital has a board of six trustees, appointed 

by the Governor for six years and removable by him. Each board 

appoints the superintendent and other officers. A representative 

from each board of trustees, together with four members of the 

19 



l86 INSTITUTIONAL CARE OF THE INSANE 

board of regents of the University, compose the board of trustees 
of the Psychopathic Hospital, which is connected with the Univer- 
sity of Michigan. The board for the control of the institution for 
the dangerous insane at Ionia is composed of three members, 
elected from the boards of trustees of three institutions for the 
insane in the lower peninsula. 

In Mississippi a board of trustees of five members, three of 
whom are physicians, is appointed by the Governor for each hos- 
pital for two years. The Governor is ex-officio president of both 
boards. The superintendent is appointed by the Governor for a 
term of four years and may be removed for cause. 

In Missouri each hospital is under a board of five trustees, 
appointed by the Governor for four years. The trustees appoint 
the superintendent and other officers and may remove all at their 
pleasure, except the superintendent ; the latter may be removed 
for incompetency or misconduct. 

In Nebraska two of the hospitals, built primarily for the care 
of the chronic insane, are under the control of the Board of Public 
Lands and Buildings. The Nebraska State Hospital at Lincoln 
has a board of three trustees, appointed by the Governor for six 
years. The trustees appoint the superintendent and assistant for 
a term of six years. 

In New Hampshire the State Hospital had a board of twelve 
trustees, appointed by the Governor and council and serving with- 
out pay. In 1913 a board of control consisting of five members, 
three persons serving without pay and the Governor and chairman 
of the State Board of Charities ex-officio, was established. This 
board of control, after two years, was replaced by a board of 
ten trustees appointed by the Governor and council to manage the 
penal and charitable institutions of the state. These trustees have 
varying terms of service and serve without pay. 

In New Jersey each state hospital has a board of eight managers, 
appointed by the Governor for a period of five years. Each board 
appoints a medical director, assistant and warden. A committee of 
two members from each board must visit each county insane asy- 
lum in their respective districts annually and make recommenda- 
tions in reference to them in their annual report. This seems to 
be the only instance in a state hospital where a board of trustees 
appointed to govern an institution is given power of inspection and 



PRESENT GOVERNMENT OF INSTITUTIONS 187 

advice in reference to other institutions in the district of the 
hospital. 

In New Mexico a board of five directors is appointed by the 
Governor. The board elects the chief executive of^cer, who, with 
its consent, employs physicians, nurses, guards and other necessary 
employes and fixes their salaries. In this institution the president 
of the board, a layman, evidently exercises the chief functions in 
its management. 

In New York each state hospital has a board of seven managers, 
two of whom must be women, appointed for terms of seven years. 
The State Hospital Commission, however, appoints the superinten- 
dent subject to the approval of the board of managers in each insti- 
tution. The superintendent of the institution may be removed by 
a majority vote of the board of managers, provided its action be 
approved by the State Hospital Commission. The ultimate control 
of institutions in New York rests with the State Hospital Com- 
mission, which, in addition to advisory powers, possesses absolute 
control in all essential matters. 

In North Carolina each hospital has a board of nine directors, 
who serve without pay and are appointed by the Governor for 
terms of six years. The directors appoint the superintendent for 
a term of six years. The superintendent appoints all subordinate 
officers and may remove them for cause. 

In North Dakota the board of trustees is appointed by the 
Governor for four years. The trustees in turn appoint the super- 
intendent, the assistant physicians, " guardians," nurses and other 
employees and may also discharge them at will. 

In Oklahoma the institutions are governed by a board of three 
trustees, each appointed by the Governor for three years. Two 
boards have the power to appoint the superintendent of the hos- 
pital, but the superintendent of a third hospital is appointed by the 
Governor for a term of four years. The trustees have the power 
to remove all officers and employes. 

In Pennsylvania state hospitals are controlled by individual 
boards, consisting generally of nine trustees, appointed by the 
Governor for three years. The trustees appoint the superintendent 
of each institution, who is subject to removal or may be re-elected 
for a term of ten years. 



l88 INSTITUTIONAL CARE OF THE INSANE 

In South Carolina the State Hospital has a board of five regents, 
appointed by the Governor for six years. The method of the 
appointment of the superintendent is not given, but he is probably 
appointed by the Governor. 

In Tennessee each hospital has a board of five trustees, appointed 
from the district in which the hospital is located for a term of six 
years. The trustees appoint a superintendent for a period of eight 
years. The superintendent, subject to the control of the trustees, 
has entire control of the appointment and dismissal of all sub- 
ordinates. 

In Texas each hospital has a board of five managers, appointed 
by the Governor for two years. The managers elect the superin- 
tendent and appoint other officers and employees on his nomination 
and discharge them on his recommendation. 

In Vermont the State Hospital has a board of three trustees, 
appointed by the Governor for six years, which board appoints the 
superintendent, steward, chaplain and matron and other necessary 
officers. 

In Virginia each state hospital has a special board of three direc- 
tors, appointed by the Governor for six years. All the boards of 
special directors combined form a general board for the govern- 
ment of the state hospitals. The general board of directors meets 
annually at each hospital and appoints the respective superin- 
tendents for a period of four years. The special board of each 
hospital, subject to the approval of the general board, appoints for 
terms of four years all other resident officers. The superintendents 
of the hospitals appoint, remove and employ all subordinates 
except the resident officers. 

It is evident from the above summary that, as a rule, there is a 
very clear and definite recognition of the principle of the respon- 
sibility of boards in the government of most of the hospitals for the 
insane. Each board is generally appointed by the Governor, with 
the advice and consent of the Senate, and is made responsible for 
the management and control of the institution, appointing the 
superintendent and giving to him certain definite powers, subject 
to the control of the board. It is interesting to observe, however, 
that in some states, where hospitals are governed in this manner 
by boards of directors, the Governor has the power to appoint the 
superintendent. In New York, as has already been pointed out, 



PRESENT GOVERNMENT OF INSTITUTIONS 189 

the appointment of the superintendent does not rest wholly with 
the board of managers, althoue^h the board of managers has an 
implied veto power and also may remove an obnoxious superin- 
tendent, provided the State Hospital Commission approves. 

It is evident that the boards of trustees of state institutions are 
at present in a transitional state. There is a tendency to reduce the 
membership of boards and to give compensation for service. In 
some states the compensation is ample for the duties performed ; 
in others it is simply a per diem rate, with traveling expenses. 

It should be observed that where state supervision exists 
through boards of charities and corrections, little control seems 
to be exercised over the institution. Where there are boards of 
control or of administration, however, as in Illinois, Iowa, Kansas, 
Minnesota, Ohio and other states, the supervision of the institu- 
tions seems much more thorough than where the boards possess 
advisory powers similar to the old-fashioned boards of charities 
and corrections. It is also interesting to notice how rapidly during 
the past two decades a tendency has developed toward the estab- 
lishment of so-called boards of control, especially in the Middle 
West and the Western states. The boards of control seem in 
many instances to have been composed originally of state officers, 
serving ex-officio, who had other official duties. In a number of 
states these ex-ofUcio boards are still in charge of institutions. 
Thus in Arizona, the State Hospital at Phoenix is managed by a 
State Board of Control, consisting of the Governor, the State 
Auditor and one citizen appointed for two years. 

In Florida the State Hospital is governed by a Board of Com- 
missioners of State Institutions, consisting of the Governor and 
administrative officers of the executive department, who serve 
ex-oMcio. 

In Montana there is a State Board of Commissioners for the 
Insane, consisting of the Governor, the Secretary of State, and the 
Attorney-General, all serving as ex-oificio members. 

In Nebraska two hospitals for the chronic insane are under the 
control of the Board of Public Lands and Buildings, composed of 
the Commissioner of Public Lands and Buildings, the Secretary 
of State, the State Treasurer and the Attorney-General, who serve 
as ex-oificio members. 



190 INSTITUTIONAL CARE OF THE INSANE 

In Nevada the State Hospital is under the control of a board of 
commissioners, consisting of the Governor, the State Treasurer 
and State Comptroller, who serve as ex-officio members. 

In Oregon the Board of Trustees, as it is called, is composed of 
the Governor, the Secretary of State and the State Treasurer, who 
serve as ex-officio members. 

In Utah the Board of Insanity is composed of the Governor, the 
State Treasurer and the State Auditor, all serving as ex-officio 
members. 

In Wyoming the State Hospital is controlled by a State Board 
of Charities and Reforms, consisting of the Governor, the Secre- 
tary of State, the State Auditor and the State Superintendent of 
Public Instruction, all of whom serve ex-officio. 

It will be noticed that nearly all the states in which these ex- 
officio boards exist are small, with comparatively limited hospital 
facilities and without a great burden of responsibility in their 
management. It is to be feared that boards composed wholly of 
ex-officio members cannot be very efficient, because of a division of 
interest and the lack of any stimulus to improvement. 

Institutions under the control of ex-officio boards are apt to be 
managed either by professional politicians or else by one active 
member, with an eye to his re-election or his political aggrandize- 
ment, and with little regard to the good of patients. 

As a result of the success which attended the boards of control 
appointed originally in Wisconsin and Iowa and afterwards 
extending to other states, there is now a definite policy on the part 
of many of the Middle Western and Western states to provide for 
the government of institutions for the insane by a separate body 
charged in some cases with the duty of caring for the insane alone 
and in others with the control of other charitable institutions. 

In Colorado such a board, which is known as the Board of 
Lunacy Commissioners, consists of three members, appointed by 
the Governor for a period of six years, with an adequate salary. 

In Illinois the board is known as the Board of Administration 
and consists of five members, appointed for a period of six years, 
with salary. 

In Iowa there is a Board of Control consisting of three mem- 
bers, appointed for six years, with salary. 



PRESENT GOVERNMENT OF INSTITUTIONS IQI 

In Kansas the central board, which is known as the Board of 
Control of State Charities, consists of three members, appointed 
for a period of four years, with salary. 

In Kentucky the board is known as the Board of Control, and 
consists of four members appointed for four years, with salary. 

In Minnesota the duties of the board are much enlarged. It is 
known as the State Board of Control for all Charitable Institu- 
tions. It consists of three members, appointed for a period of six 
years, with salary. 

In Ohio the board is known as the Board of Administration. 
This board also has enlarged powers and manages all state insti- 
tutions. It consists of four members, appointed for four years, 
with salary. 

In Rhode Island the state institutions are managed by a Board 
of State Charities and Corrections, consisting of nine members, 
appointed for a period of six years. Although this board is not so 
denominated in the act, it performs duties of the same kind as 
other boards of control. 

In South Dakota the institutions for the insane are managed by 
a State Board of Charities and Corrections, consisting of five 
members, appointed for a period of six years. 

In Washington there is a State Board of Control, consisting of 
three members, appointed for a period of six years, with salary. 

In West Virginia there is a State Board of Control, consisting 
of three members, appointed for six years, with salary. 

In Wisconsin all the affairs of the insane are looked after by a 
State Board of Control, consisting of five members, one of them 
a woman, appointed for five years, with salary. 

The statement has already been made that largely owing to the 
influence which governed the organization of the state hospitals in 
Massachusetts, Vermont, New Hampshire and New York, boards 
of trustees managed the institutions in behalf of the state, as 
separate corporations. Many institutions followed with a similar 
organization. As a rule the trustees, directors, managers, regents 
or governors, whatever they were called, were appointed by the 
Governor of the state, by and with the advice and consent of the 
Senate, and sometimes without it, as is the case in Massachusetts. 

No thought of political control or political influence entered 
into the original boards of trustees. The trustees were appointed 



192 INSTITUTIONAL CARE OF THE INSANE 

because of known reputation and business ability and were ex- 
pected to attend to the affairs of the institution with an eye single 
to the prosperity and success of the institution. 

In the earlier days they served without pay, and they gave an 
amount of time and service to the affairs of the institution which 
could not have been adequately rewarded by any salary, because 
they brought a higher degree of experience and ability than the 
state could afford to reward. They were judges, lawyers, phy- 
sicians, bankers and business men, all of them leading busy lives. 
Later on, after the lapse of years, as the system extended to some 
of the newer states, political influences crept in. In Ohio, for 
example, it soon became the custom to change the board of 
trustees whenever the political parties in that closely divided state 
changed places. Upon the election of a Democratic Governor in 
1877 an edict went forth that the superintendents of the state insti- 
tutions must be in " harmony," as it was expressed, with the 
political views of the Governor. This edict especially affected Dr. 
Richard Gundry, a distinguished and able superintendent, who 
had planned, managed and built several institutions for the insane 
in that state during an active service of many years. Dr. Gundry 
had served 23 years faithfully, without partisanship, and most 
efificiently, and there seemed little necessity for such " harmony," 
since the Governor was elected for a single year. Such, however, 
was the edict. He was accordingly removed from office (as were 
also all others in the institution of similar inharmonious political 
faith) and compelled to seek another institution in a distant state. 
Similar overturnings took place in Missouri, Virginia, Illinois, 
Indiana, Kansas, Texas and Washington as the result of political 
changes. The most flagrant instance of such a perversion of the 
purposes of a charitable institution took place in the State of Kan- 
sas, where a mushroom political party sprang into existence and 
speedily fell into deserved oblivion. Every person connected with 
the State Hospital at Topeka was removed and a new superin- 
tendent, physicians, nurses, orderlies, maids, cooks, farm hands, 
teamsters and day laborers were brought in, because they were in 
" harmony " with the new party. One hospital for the insane in 
Ohio was reputed to have had 12 superintendents in 11 years and 
other states suffered similarly, though not so intensively. The 
list of states which thus dishonored themselves is a long and 
sad one. 



PRESENT GOVERNMENT OF INSTITUTIONS I93 

In some states it was customary to appoint trustees from certain 
specified districts, with a preponderant number from the county 
immediately surrounding the hospital. In Iowa we learn from a 
statement prepared some years ago by a former superintendent 
that a resident trustee was appointed in each institution, to whom 
were committed many matters connected with the local work of the 
hospital. He was often made the treasurer, perhaps the chairman, 
of the executive committee, and was generally recognized as hav- 
ing a predominant voice in all local affairs. 

In Michigan two trustees were appointed to reside at the seat of 
the hospital to act as an executive committee. 

Boards of managers or trustees, as a rule, did excellent service 
in the management of institutions, but there were disadvantages. 
In some instances the position became a reward for political ser- 
vice, and occasionally, although rarely, there was a suspicion that 
the local trustee profited by contracts, or by the purchase of sup- 
plies, though he probably did not do so directly. 

In some instances, where the trustee acted as treasurer, he 
deposited the funds of the hospital in a bank which he owned or 
controlled. Recently, in California, a scandal has arisen because 
of a purchase of hay, an important supply, ostensibly purchased 
for the use of the institution. Through the collusion of two officers 
of the institution, the amount of hay paid for through false bills 
and weights was largely in excess of the amount purchased, the 
proceeds being divided between the guilty parties. In other 
instances the trustees interfered in the appointment and discharge 
of employees and thus exercised a baneful influence upon the dis- 
cipline and morale of the institution. In more than one state the 
medical officers of the institutions became actively engaged in 
politics and ordered their male employees to vote in behalf of one 
or the other political party. In one instance the superintendent 
of a state hospital organized a glee club to gladden political meet- 
ings with song. 

Another disadvantage which grew out of the trustee system w^as 
that with several institutions in a given state and the natural rivalry 
and emulation such as frequently arose between them, individual 
boards of trustees or committees often visited the legislature to 
lobby for appropriations to improve their own institutions, with 
but little regard for the welfare of the whole state. In many 



194 INSTITUTIONAL CARE OF THE INSANE 

instances, where institutions possessed active lobbyists or enter- 
prisinc: trustees, they secured Hberal appropriations and larger 
sums of money than other institutions. 

This frequently gave rise to jealousy and heart-burning between 
officers, as well as to a waste of public money. Hence it is not 
strange that in some of the Western states, where evils of this 
character had existed to a great degree, a movement to establish 
a central board of control for all the institutions was agitated and 
became popular. Such a central board of control would view all 
institutions impartially and have no pecuniary interest in one 
beyond another. It would consider the needs of the institution in 
deciding upon improvements, new buildings and additional lands, 
and be guided wholly by the welfare of the institution. There is 
a degree of danger, however, that under such a board of control, 
which stands between an individual institution and the state and 
exercises unlimited control, all initiative on the part of the officers 
of the individual institution may be lost. They cannot originate 
any new policy, nor can they act without the consent of the board 
of control, which, conceivably, may be governed by motives of 
economy rather than by a desire to further the good of the 
institution. 

In states like Ohio, Iowa and Minnesota we are assured by those 
who know that such conditions do not exist. Wise boards of con- 
trol have allowed institutions to develop in their own way and they 
have been absolutely free from any political bias in the selection of 
a superintendent, to whom has been committed, without any 
restriction, the selection and appointment of employees and their 
discharge for cause. Such a board of control has been an impor- 
tant factor in regulating the wages of employees and establishing 
a uniform grade of service throughout the state. It has improved 
the living conditions of employees, giving them better housing, 
better food and better living conditions. All persons agree that in 
Minnesota the condition of patients has been improved. Supplies 
are bought more economically than was formerly the case and 
have been standardized so that all patients throughout the state 
are treated alike. There has been a marked improvement in food, 
clothing and general surroundings. Many of these betterments 
have been rendered possible by economies which have prevented 
waste or careless inspection of food supplies. Political control has 



PRESENT GOVERNMENT OF INSTITUTIONS I95 

become a thing of the past and institutions are now managed in 
the interest of the whole state and not of any part of it. 

In Iowa we are told that politicians have been wholly eliminated 
from the hospitals and that in the selection of officers and employees 
a high form of civil service or merit test has been instituted. There 
have been economies of purchase and uniformity of accounts, so 
that the accounts of one institution may be compared with those of 
others. There also has been an impartial consideration of the 
actual needs of the institution at the hands of a board of experi- 
enced, capable and high-minded men. As a result of this the 
standard of care has been raised. Greater confidence in the state 
institutions has also developed throughout the state, because of the 
confidence placed by the public in the integrity, ability and good 
sense of the board of control, owing to the fact that it is a central 
board, responsible to the whole state and not to individuals. 



III. 

METHODS OF INVESTIGATION OF PUBLIC 
INSTITUTIONS. 

California. 

The State Commission in Lunacy consisting of five members, 
to wit : The General Superintendent of the State Hospitals, the 
Secretary of the State Board of Health, and the three members 
of the State Board of Examiners, is authorized to make an inves- 
tigation of the conduct of institutions for the insane. 

When the commission has reason to believe that any person held 
in custody as insane or incompetent is wrongfully deprived of his 
liberty, or is cruelly or negligently treated, or inadequate provision 
is made for his skillful medical care, proper supervision and safe- 
keeping, it may ascertain the facts, or may order an investigation 
of the facts by one or all of its members. It or the commission con- 
ducting the proceedings may issue compulsory process for the 
attendance of witnesses and the production of papers, and exercise 
the powers conferred upon a referee in a superior court. The 
commission may make such orders for the care and treatment of 
such person as it may deem proper. Whenever the commission 
undertakes an investigation into the general management and 
administration of any hospital for the insane or incompetents or 
places of detention for the alleged insane or incompetents, it may 
give notice to the Attorney General of such investigation, who 
must appear personally or by deputy and examine witnesses who 
may be in attendance. The commission, or any member thereof, 
may at any time visit and examine the inmates of any county, city 
and county, or city almshouse, to ascertain if insane persons are 
kept therein. When complaint is made to the commission regard- 
ing the officers of any hospital or institution for the insane or other 
incompetents, or regarding the management thereof, or of any 
person detained therein, or regarding any person held in custody 
as insane or incompetent, the commission may, before making an 
examination regarding such complaint, require the same to be 
made in writing- and sworn to before an officer authorized to ad- 



METHODS OF INVESTIGATION OF PUBLIC INSTITUTIONS I97 

minister oaths, and on receiving such complaint, sworn to if 
required by the commission, the commission shall direct that copy 
of such complaint be served on the authorities of the hospital or 
institution or the person against whom complaint is made, together 
with notice of time and place of such investigation as the com- 
mission may direct. 

Colorado. 

The State Board of Charities, upon request of the Governor or 
of the general assembly, or upon sworn complaint of two or more 
citizens, or upon its own motion, may make an investigation by the 
whole board or by a committee thereof of any institution. The 
board can compel the attendance of witnesses, etc. A report of 
such investigation, with findings and recommendations, must be 
filed with the Governor. 

Also, upon formal complaint, the board may make inquiry into 
the conduct and management of private eleemosynary institutions, 
societies and corporations, and may revoke any licenses granted to 
such institutions. 

Illinois. 

The State Board of Administration and State Charities Com- 
mission both have power to conduct investigations of public, 
charitable or correctional institutions, also of institutions caring 
for children or treating mental and nervous diseases. Investiga- 
tions may be initiated by either board or conducted in conjunction, 
at the request of the Governor. 

Xo rules or methods are prescribed for the investigation. Inves- 
tigations cannot be compelled by extraneous authority, but it is 
the board's policy to investigate on receipt of any complaint. If 
newspaper accounts or rumors are of such a character as to war- 
rant proceedings, an investigation is made. If the investigation 
is at the request of the Governor, a report is made to him ; other- 
wise it is filed in the records of the body making the investigation. 

Indiana. 
The State Board of Charities in its discretion may investigate 
penal and charitable institutions either by the board or by a com- 
mittee of its members. It can compel the attendance of witnesses, 
etc. A report of the investigation is made to the Governor, and 



198 INSTITUTIONAL CARE OF THE INSANE 

must be submitted by him with his suggestions to the general 
assembly. 

The board makes such rules and orders for the regulations of 
these proceedings as it may deem necessary. 

Iowa. 

The State Board of Control has power to investigate all state 
institutions under its control and all county and private institutions 
in which insane persons are kept. 

The authority over state institutions carries with it power to 
correct abuses. Authority over county and private institutions in 
which insane persons are kept is confined to advisory powers. The 
Governor frequently orders investigations and appoints commit- 
tees for that purpose. 

No state law prescribes methods of investigation except such 
as are found in the statutes in regard to powers of the board. The 
attendance of witnesses can be compelled. 

No extraneous authority except the general assembly can compel 
an investigation. 

The report of an investigation containing evidence of witnesses 
and conclusions of the board must be filed with the Governor. 

Kansas. 

The State Board of Control is authorized to investigate state 
institutions on complaint coming from a reliable source, or from 
any employee of the institution, or from any citizen of the state, 
when in the judgment of the board the interests of the institution 
or the welfare of the state demand such investigation. The board 
can compel the attendance of witnesses, etc. Whenever charges 
are made by any person or ])ersons and circulated within the state 
and deemed reliable, notice is to be given to the official concerned 
and pending the investigation the Governor shall relieve the offtcial 
from duty. 

Maryland. 

In Maryland there are two bodies which have the right to 
investigate public charitable and correctional institutions. First, 
the State Lunacy Commission has power to investigate institutions 
which care for persons suffering from mental troubles. Second, 



METHODS OF INVESTIGATION OF PUBLIC INSTITUTIONS I99 

the Board of State Aid and Charities is given power " to make any 
investigation it sees fit." In addition, of course, the Governor or 
legislature has power to appoint special commissions. 

With regard to the Lunacy Commission, the lunacy laws pre- 
scribe methods of procedure. Otherwise there is no state law 
prescribing rules or methods of procedure. 

Massachusetts. 

The State Board of Insanity has the right of investigation of 
institutions for the care of the insane, feeble-minded, epileptic and 
inebriate. It has the right to investigate questions of sanity and 
the condition of persons restrained of their liberty. It often acts 
as a board of appeal in adjusting differences and complaints. 

The Governor can order an investigation of an institution and 
the report of the same must be made to him. No methods of 
procedure are prescribed in this state for conducting such in- 
vestigations. 

Michigan. 

In this state the Board of State Commissioners for the general 
supervision of charitable, penal, pauper and reformatory institu- 
tions is empowered to investigate all such institutions. The said 
commissioners or either of them shall also make special investi- 
gation into any alleged abuse in any of the institutions. They are 
authorized to visit whenever the Governor shall direct, and a 
report must be made to him within such reasonable time as he shall 
prescribe. Also the commissioners, whenever abusive treatment 
shall come to their knowledge, shall immediately investigate and 
report the facts of such abusive treatment to the Governor, with 
such recommendations as they shall deem proper. 

Missouri. 

The State Board of Charities and Corrections may by its own 
volition or upon the order of the Governor investigate any public 
charitable or correctional institution. 

There is no legal direction as to the legal procedure during such 
investigation. Witnesses are put under oath. Outside authorities 
cannot compel an investigation. When the board investigates of 
its own motion it ordinarily publishes reports. When ordered by 
the Governor it reports to the Governor. 



200 institutional care of the insane 

New Jersey. 

The State Commissioner of Charities and Corrections of New 
Jersey may, upon an order of the Governor, conduct an investiga- 
tion of any of the state institutions, and in making such investi- 
gation the Governor may appoint two citizens of the state to assist 
the commissioner. The method of conducting such investigation 
is not controlled by statute. 

No extraneous or outside parties may compel such investigation 
unless it be the power of public sentiment acting through the chief 
executive. The report of any such investigation with any con- 
clusions or recommendations resulting therefrom is made to the 
Governor. 

New York. 

The Governor of the state has authority under the statutes to 
conduct an investigation of any institution. Also the legislature 
may investigate by passing a resolution to that effect ; also district 
attorneys may investigate with the aid of the grand jury where 
crimes are alleged to have been committed. Formal charges may 
always be filed and these are carefully investigated by the state 
board or by the board of managers of the institutions or by both. 
The state board investigating reports its findings to the legislature 
as a part of its annual report. If the board of managers investi- 
gates it reports its findings to the state board. 

The statute in a general way covers methods of procedure, such 
as calling witnesses, administering oaths, etc. 

North Carolina. 

The Governor of the state, as chairman of the Board of Internal 
Improvements, has the power to have any institution investigated 
and to put witnesses on their oath. This power has been added to 
the board's duties during the last few years. 

The State Board of Public Charities has the right to investigate 
any charitable or penal institution, but not the right to put wit- 
nesses on oath. 

Nebraska. 

The Governor of Nebraska has sole authority to order an inves- 
tigation of state institutions or the management of the same. 
There is no law providing rules or methods of procedure. 



methods of investigation' of purlic ixstitutioxs 20i 

Ohio. 

Section 1354 of the code provides that the Governor may order 
the Board of State Charities or a committee thereof to investigate 
the management of a benevolent or correctional institution of the 
state. The board or committee has power to send for persons or 
papers, etc. The report of the investigation is made to the 
Governor and by him submitted to the general assembly with 
appropriate suggestions. 

The terms of this section have been by an opinion of the Attor- 
ney General limited to institutions owned and controlled by the 
state. There, therefore, seems to be no authority to extend this 
investigating power of the board to charitable and correctional 
institutions belonging to municipalities or counties. 

The State Board of Administration has power to make investi- 
gations upon its own initiative. No outside parties can com- 
pel an investigation except through successful application to the 
Governor. 

Pexxsylvaxia. 

The act of 1869, which created the Board of I'ublic Charities 
of the Commonwealth of Pennsylvania, gave it the authority to 
investigate any public, charitable or correctional institution. 

There is no state law prescribing the rules or methods of pro-, 
cedure for conducting such investigation. This is a matter entirely 
in the hands of the board itself. 

Such investigations are made either at the request of the 
Governor, legislature, or upon the sworn statement of any indi- 
vidual in the commonwealth. 

The board makes its report to the legislature and the Governor, 
or, if the case warrants it, reports its findings to the courts for 
legal action if necessary. 

Texxessee. 

The Governor, in his discretion, may at any time order an inves- 
tigation by the Board of Trustees or by a committee of its mem- 
bers of any penal, reformatory or charitable institution of the state, 
and said board or committee, in making such investigation, shall 
have power to send for persons and papers, and to administer oaths 
and affirmations, and the report of such investigation, with the 
20 



202 INSTITUTIONAL CARE OF THE INSANE 

testimony, shall be made to the Governor and shall be sumbitted by 
him, with its suggestions, to the general assembly. 

Virginia. 

The Governor may order the State Board of Charities and Cor- 
rections or any committee thereof to investigate the management 
of any state institution or any institution receiving aid from the 
state. There is no law or other authority prescribing the rules or 
methods of procedure for conducting such investigation, except in 
the law creating the state board. The State Board of Charities has 
power to administer oaths, to summon officers and employees to 
attend as witnesses and to force their attendance, and to compel 
them to produce documents and to give evidence. Such investiga- 
tion cannot be compelled by extraneous authorities or outside 
parties. The party making investigation reports its findings and 
conclusions to the Governor. Of course the general assembly has 
a right at any time to order an investigation of any public institu- 
tion or any institution receiving aid from the state. 

Washington. 

The Governor or Board of Control can order an investigation of 
any of the institutions under the supervision of the State Board 
of Control. 

There is no law or other authority prescribing rules of procedure 
other than as provided in the Board of Control law. 

Investigations cannot be compelled by outside persons or author- 
ity, but if the proper showing is made to the Governor or to the 
Board of Control, investigations are made. 

Reports of findings in investigations are made to the Governor. 

Wisconsin. 

Section 565 of the Wisconsin statutes provides the facilities for 
investigations of charitable and correctional institutions. The 
Board of Control under that law has power to make an investiga- 
tion of any institution in which persons are confined by commit- 
ment. The board has not adopted any rules governing investiga- 
tions, but many investigations have been made under the authority 
given in that statute. The board has investigated poorhouses, 



METHODS OF INVESTIGATION OF PUBLIC INSTITUTIONS 2O3 

county asylums and state institutions. The report is simply made 
and filed in the office of the board. Sometimes the Governor 
requests the board to make an investigation of a given institution 
and when that is done the report is made to the Governor with a 
transcript of the testimony taken. 

Under the provisions of section 565 the board has power to 
compel the attendance of witnesses at investigations and to expend 
such moneys for expert testimony as the board deems proper. 

Dominion of Canada, 
province of ontario. 

The Provincial Secretary has charge of all public institutions 
such as prisons, gaols, insane asylums, etc. There is an Inspector 
of Asylums and Prisons who occupies much the same position as 
the different commissions that exist in many of the United States. 
The Inspector is a permanent official and gives his undivided time 
to the work. The Inspector occupies a position between the min- 
ister, the deputy minister on one hand and institutional detail on 
the other. 

An investigation can be ordered by the minister, the deputy 
minister, or the inspector. 



IV. 
DEVELOPMENT OF HOSPITAL ARCHITECTURE. 

The architectural evohition which characterized hospital con- 
struction during- the building era in the early part of the nineteenth 
century deserves consideration. 

Prior to the year 1840 there was little that was distinctive in any 
of the buildings, though at one or two, as the Friends' Asylum at 
Frankford and the Hartford Retreat, an attempt was made to 
reproduce the plans of the York Retreat in England, which had 
powerfully influenced the philanthropic movement to better the 
condition of the insane. 

The Hartford Retreat and the Friends' Asylum, in turn, unques- 
tionably influenced the construction of many early private or semi- 
public institutions in New England, as, for example, the Asylum at 
Brattleboro, Vt. ; the New Hampshire State Hospital ; the State 
Flospital at Worcester, Mass., and the State Hospital at Augusta, 
Me. In these buildings an effort was made to get the largest 
amount of accommodation for patients at the least possible cost. 
The condition of the New England states was still that of com- 
munities which had not emerged from pioneer hardships — Ver- 
mont, New Hampshire and Maine being all inhabited by a hardy, 
thrifty, but comparatively poor class of citizens. The soil was not 
productive ; much of the surface of the country w^as covered 
with forests and the cultivation of the land was but imperfectly 
developed. 

The influence of England was shown in building the McLean 
Hospital, the Butler Hospital, the State Hospital at Columbia, 
S. C, and, possibly, the New York State Hospital at Utica. The 
McLean Hospital and the Columbia State Hospital are sufficiently 
alike to suggest a common origin, which may have been from 
England, or was possibly an evolution of the Old Province House, 
which formed the nucleus of the former institution. It is interest- 
ing to note that the original plans of the hospital at Columbia, 
S. C, were found a few years ago at the McLean Hospital. They 
were prepared by Robert Mills, a noted architect of his time, who 
lived in Washington and practised his profession in Washington, 



DEVELOPMENT OF HOSPITAL ARCHITECTURE 205 

Baltimore, Charleston and other Atlantic seaboard cities. The 
plans for the South Carolina institution may have been Robert 
Mills' modifications of the original plan of the McLean Hospital. 
The plan of the institution at Staunton, Va., gives many sugges- 
tions of French origin and influence. I know of no institution 
which originally had a pleasanter outlook or better facilities for 
the segregation of patients of different classes than the Western 
State Hospital at Staunton, Va. Unfortunately, owing to the 
necessity of securing accommodation for the insane at the least 
possible outlay of money, during the period of poverty which fol- 
lowed the civil war, large barrack-like additions were constructed, 
in connection with the original buildings, which revolutionized 
the plan and marred its effect very badly. 

There was, however, no uniform plan of hospital construction 
until Dr. Thomas S. Kirkbride, of Philadelphia, evolved the plan 
of the Pennsylvania Hospital. The first building in West Phila- 
delphia, now known as the Department for Females, was built 
after a plan brought from England, which had many defects. An 
unnecessary half-story, rendered possible by excavating the soil 
and building an area, had been added as a basement. This was 
unquestionably intended to increase the architectural effect of the 
building, but the device was unfortunate. After studying the 
defects of the original building Dr. Kirkbride devised a plan which 
served as a prototype of institutions throughout the country. It 
consisted, in effect, of an administration building, of somewhat 
more commanding and imposing architecture than the wings, 
which was to be used for offices, store-rooms, and kitchen as well 
as for a residence for the superintendent and medical officers. On 
either side of the administration building were wings, extending 
usually about 150 feet, each wing to be occupied by one of the 
sexes. These wings terminated in cross sections which gave 
accommodation to water-closets, clothing rooms, and bath-rooms, 
while at right angles from the cross sections were other wings 
which could be extended indefinitely. In some instances four sets 
of longitudinal wings and cross sections were arranged for the 
care of different classes of patients. The theory was that con- 
valescents and quiet patients would occupy the wards close to the 
administration building. Patients in an intermediate state would 
occupy the wards nearest the convalescent ward, and patients who 



206 INSTITUTIONAL CARE OF THE INSANE 

suffered from severe excitement or were especially objectionable 
by reason of noisy outcries or turbulent conduct were placed as 
far away from other patients and from the administration building 
as possible. Each ward was complete in itself, that is, each pos- 
sessed a bath-room, water-closets, clothes-room, dining room, etc. 
By means of miniature railways with provision cars and dumb 
waiters for service, it was possible to supply food from a central 
kitchen adjacent to the administration building. 

The plans, as formulated in a series of 26 propositions by Dr. 
Kirkbride, were formally adopted by the Association of Superin- 
tendents of Institutions and, as a result, buildings were constructed 
on the Kirkbride plan in almost all the states of the Union. I can 
recall them without effort in New Jersey, Ohio, Michigan, Illinois, 
Wisconsin, Kentucky, Tennessee, North Carolina, Georgia, Ala- 
bama, Louisiana, Mississippi, Texas, Iowa, Minnesota, Nebraska, 
Kansas, Virginia, Maryland, District of Columbia, West Virginia, 
Missouri, New York, Massachusetts, Connecticut, Maine, Utah 
and California. Some or all of the institutions for the insane in 
each of these states were built according to the Kirkbride linear 
plan, which had many advantages. The buildings were not expen- 
sive and they were easily managed, which was an important matter 
at a time when the conception of the superintendent was that of an 
officer who attended to all the details of the institution. He was 
supposed to have medical charge of every patient ; he was generally 
treasurer; he looked after the purchase of supplies; and he had 
the responsibility of the management of the kitchen, stables, farm 
and all other business enterprises connected with the hospital. 

The buildings thus erected were usually semi-fireproof. They 
gave easy access to the grounds and from their arrangement it was 
practicable to add to them without destroying the architectural 
symmetry. Unfortunately, however, the addition of successive 
wings sometimes rendered the farthest building difficult of access. 
In the Buffalo State Hospital, for example, which is probably the 
most extreme type of building constructed after this plan, the 
medical officers must walk a distance of half a mile from the 
administration building to reach the farthest ward on either side. 
The buildings were usually heated by steam, but if they were in 
exposed situations they were difficult to heat. It should be added 
that the buildings at Utica and at the Pennsylvania Hospital 



DEVELOPMENT OF HOSPITAL ARCHITECTURE 207 

were originally heated by hot air furnaces, which proved to be 
inadequate, so that early in their history a change was made to 
heating by steam, distributed in coils in the basement, ventilation 
being effected by currents of air entering through air-chambers, 
also in the basement, passing over the same steam coils, and reach- 
ing the wards as warm fresh air, a system which is now known as 
indirect radiation. In most institutions a ventilating fan was pro- 
vided to force a positive circulation of air through underground 
ducts over coils of iron pipe heated by steam and into the wards 
through inlet flues. Outlet flues from the wards usually termi- 
nated in the attic and foul air was supposed to find its way out 
through louvres in cupolas. Unfortunately, although forced ven- 
tilation was provided in many institutions, the system was not 
always effective and institutions, as a whole, suffered from too 
much heat and too little fresh air. 

For many years the " propositions," modified from time to time 
as exigencies demanded, formed a set of cast iron rules, which 
governed the construction of hospitals. At first the scheme con- 
templated institutions of not more than 200 patients. Later on, 
through force of circumstances, it became necessary to sanction 
the erection of separate departments for each sex, as at the Penn- 
sylvania Hospital in Philadelphia, the Indiana State Hospital and 
the Michigan Hospital at Kalamazoo. These departments were 
not individually to accommodate more than 250 or 300 patients 
each, but the whole institution thus enlarged became unwieldy and 
difficult to manage. Many accomplished superintendents felt that 
if they must have the care of 600 patients it was better from an 
administrative standpoint to have the buildings near at hand and 
easily controlled, rather than to attempt to manage two distinct 
establishments with a divided authority. Many older superin- 
tendents resented any effort to break away from the original plan. 
As we now view the question, it is apparent that while the Kirk- 
bride " propositions " were valuable in an early stage of the move- 
ment to care for the insane, and were an excellent example of 
economical and easily administered buildings, they made the mis- 
take of emphasizing too strongly the custodial features of institu- 
tions and were not sufficiently flexible to meet the requirements of 
all classes of patients. This became so apparent that in many older 
institutions, presided over by men thoroughly in sympathy with 



208 INSTITLTIONAL CARE OF THE INSANE 

tlie orie^inal " propositions," cottages were added to accommodate 
the chronic insane, farm laborers, and harmless persons requiring 
custodial care rather than institutional treatment. At first the 
intention was to make these cottages like private houses, to accom- 
modate 20 or 30 patients. Soon, however, the necessity of reliev- 
ing institutions of the constantly increasing burden of chronic 
patients led many men to advise the construction of cottages con- 
taining 50, 100, 200 and even 300 patients. These buildings, as a 
rule, were simple in construction and accommodated patients 
almost wholly in dormitories. Partly to secure more room and 
partly to insure a greater economy in feeding patients, there grew 
up kitchens, dining and service rooms, at a central point to which 
patients from all parts of the institution were sent to take their 
meals. This arrangement allowed the food to be distributed with 
less expense, and in a more appetizing condition as regards both 
cooking and service. It also enabled many institutions to convert 
the individual dining rooms in every ward into dormitories and 
thus to accommodate a larger number of patients. 

The first notable departure from the original " propositions " 
was at Willard, N. Y., where the necessity of accommodating 2000 
patients of the chronic class at a comparatively low cost per capita 
rendered it essential to plan a series of block buildings about a cen- 
tral hospital and administration building. Dr. Chapin, the able 
planner of Willard, who was also the first superintendent, always 
declared that he acquiesced reluctantly in the plan of an adminis- 
tration building with adjacent wards on the Kirkbride plan and 
only gave his consent because general sentiment was overwhelm- 
ingly in favor of such provision. All experts who were consulted 
had grave doubts as to the wisdom of providing for patients in any 
other manner and were not favorably impressed with the utility of 
detached buildings, which afterwards became a feature at Willard. 
It was unfortunately a part of the original plan to utilize a large 
building uj)on the estate, which had formerly been occupied as an 
agricultural college. In converting this building into wards for 
patients many mistakes which had been made in earlier institutions 
were inevitably repeated. Eventually the danger of fire in a high 
building, not fireproof and crowded with helpless patients, com- 
pelled the erection of infirmary buildings for the care of such 



DEVELOPMENT OF HOSPITAL ARCHITECTURE 209 

feeble and helpless people. The old agricultural college was then 
reduced from four to two stories and practically rebuilt. 

The first institution to be constructed on what is known as the 
cottage plan was the Kankakee State Hospital, which owed its 
inception to the versatility of the late Fred. H. Wines, then secre- 
tary of the Illinois Board of State Charities. Mr. Wines had felt 
for a long time that the custom of erecting uniform buildings for 
different classes of the insane failed to meet the requirements of 
patients and conceived the plan of reproducing on an ample tract 
of land the conditions of a country village. The initiative was 
undoubtedly his, but the credit of the details of the institution was 
largely due to Dr. Dewey, who entered into his plans with great 
enthusiasm. Unfortunately, the mistake was made of constructing 
an administration building on a large scale with wards adjoining. 
This procedure, as at Willard, increased the initial cost of the 
enterprise unduly and unquestionably interfered to some extent 
with the development of the scheme as it originally appeared to the 
mind of Mr. Wines. The village idea has always been attractive 
to many who are interested in provision for the insane, but in some 
instances the village conception has increased the difficvilties of 
administration and added largely to the cost of construction, 
because, instead of a village, the ambitious architects have under- 
taken to make a town. Probably the most prominent example of 
this is shown in the Craig Colony at Sonyea, X. Y. Here no expen- 
sive w-ards or monumental administration buildings are required 
and the condition of patients is such as to permit free open air 
life with a minimum of control. The result has been the erection 
of a very large number of buildings on each bank of a deep ravine 
which separates the two sexes. The institution, in fact, consists 
of two villages with 70 or 80 dififerent buildings. The effect upon 
the visitor is not wholly pleasant. The buildings are expensive to 
keep in order, because of the large extent of roof space where no 
building is above two stories in height, while if such buildings are 
not kept in perfect repair, or if they become discolored by 
smoke and stained by weather, they do not present an attractive 
appearance. 

The institution at Kankakee was constructed in streets and with 
groups of somewhat expensive stone cottages. Some of the build- 
ings had an independent heating installation, but the majority 



2IO INSTITUTIONAL CARE OF THE INSANE 

were heated from a central point. In view of the claims made by 
those who advocated the cottage plan that in case of fire patients 
would be much less liable to danger and could be gotten into the 
open air with little difficulty, it is interesting to remember that 
a destructive fire in one of these cottages with considerable loss 
of life occurred early in the history of the institution. 

It has always been a matter of regret that before the final elabo- 
ration of the Kankakee State Hospital a reorganization of all the 
institutions of Illinois, in the interest of a political party which 
had recently come into power, drove out of the service all persons 
who had been interested in its true development, including Mr. 
Wines and Dr. Dewey. The development of the institutions as a 
consistent cottage system ceased ; whatever has been done since 
has been accomplished in a haphazard manner with a view to 
sheltering patients, rather than to providing appropriate buildings. 

The next institution upon the cottage plan to command wide 
attention was built at Toledo, Ohio, largely as the result of the 
efl^orts of General Brinckerhofif, a member of the Board of Char- 
ities, and the Rev. Dr. Byers, its secretary, who induced a com- 
mission from Ohio to visit Kankakee, in order to confer with Mr. 
Wines in reference to the village plan. The committee recom- 
mended the adoption of the cottage plan in all particulars, with 
small detached buildings for the accommodation of different 
classes of patients and two large congregate dining rooms, one for 
each sex. As might be expected in building such an institution 
certain mistakes were made, which, with more experience, might 
have been avoided. 

The site chosen was not favorable and the buildings themselves 
were not attractive, but in spite of these defects, when the com- 
pleted institution was opened to the public, it was evident that a 
new departure had been made in building for the insane. Those 
familiar with the later history of the Toledo State Hospital will 
notice that in the buildings subsequently erected a tendency 
developed to increase the size of the cottages and to rebuild them 
more expensively than was originally intended. Formerly all 
patients occupied day rooms on the lower floor and had dormitory 
accommodations on the upper floor. In the changes and additions 
which have been made during recent years both floors of many of 
the cottages have been converted into dormitories. This is in some 



DEVELOPMENT OF HOSPITAL ARCHITECTURE 211 

respects a retrogression from the original plan, due no doubt to the 
fact that the institution had become crowded and it was necessary 
to secure additional room at the smallest expense. 

The next important departure in hospital architecture was in a 
new institution at Ogdensburg, N. Y. This institution had the 
advantage of the previous experience of Dr. Peter M. Wise, of 
Willard, who had served on the commission to locate the Ogdens- 
burg Hospital and to prepare plans for it ; consequently certain 
defects which had been practically experienced at Willard were 
remedied. 

The desirability of providing for certain classes of the insane 
in separate buildings was recognized and the cottage plan adhered 
to, but these buildings were so grouped as to promote the comfort 
and convenience of all parts of the institution. There was an inex- 
pensive administration building and adjacent to it were buildings 
for cases of acute disease ; farther removed were those designed 
for convalescent cases and mild mental disorders ; beyond were 
those designed to accommodate cases suffering from excitement ; 
and, in a separate group, provision was made for chronic cases 
engaged in out-of-door work. 

The excellence of this institution has been universally attested 
by all persons who have visited it. It is doubtful, however, whether 
an institution of this type can be economically conducted in the 
cold winter climate of Northern New York, where for several 
months it is difficult for patients to take exercise in the open air 
or to go to and from central dining rooms to get their meals. So 
great an amount of isolation of patients scattered in different 
groups of buildings has necessitated a disproportionate outlay for 
fuel to keep them comfortable and has raised the inquiry whether 
the benefit gained by segregation is worth the increased cost neces- 
sitated by it. 

Somewhat later a similar experiment was attempted under more 
favorable conditions at the Springfield State Hospital, near Sykes- 
ville, Md. Here, upon a fine farm of upwards of 700 acres, with 
pleasant and convenient building sites, separated from each other 
by water courses and ravines, have been located groups of patients 
in separate and distinct buildings. There is a group for women 
patients, which constitutes a complete institution in itself, with 
dining rooms, serving rooms and kitchen, as well as a group for 



212 INSTITUTIONAL CARE OF THE INSANE 

male patients, similarly arrang^ed. Buildinj^s for chronic cases, for 
working patients, and for epileptics are situated at convenient dis- 
tances from each other, each group being under separate medical 
control, but also under the general care of the superintendent, 
whose residence is convenient to all the groups. This arrange- 
ment has proven unusually well suited to the segregation of 
patients and, because of the comparatively mild winter climate of 
Maryland, the expense has not been onerous. 

In Michigan, at the Kalamazoo State Hospital, an interesting 
modification of hospital life was secured by the establishment of 
so-called farm colonies for the chronic insane. The first attempt 
was a colony for male patients who were farm laborers, which 
was situated about three miles from the hospital and was adminis- 
tered practically as a separate institution under the charge of lay- 
managers, although visited daily by a medical officer. 

Here were gathered all the cattle of the institution and from this 
farm milk was sent in wagons to the main hospital. Here were 
pig pens and poultry yards, the occupants of which were fed by the 
garbage of the institution transported daily in covered carts to the 
colony. The cultivation of small grains, vegetables, garden berries 
and fruits was encouraged. The men who resided at the colony 
were comfortable, contented and happy and their labor became an 
important factor in the economical development of the colony. 
Unfortunately the high cost of land in the vicinity did not permit 
the extension of the colony in this location. Subsequently, to pro- 
vide for the overflow of chronic patients, a second tract of land 
was procured about two miles south of the main hospital, which 
has since been extensively developed and has contributed much to 
the comfort and welfare of both male and female patients. 

In Alabama provision was made for the colored insane at an 
abandoned military post, known as Mt. Vernon Barracks, 40 or 50 
miles from the parent institution. The barracks had been erected 
by the general government and when no longer needed were ceded 
to the state and utilized for the care of the colored insane of Ala- 
bama. The colored patients at Mt. Vernon, both men and women, 
are employed in various forms of out-door labor and their labor 
is a distinct advantage to the institution. 

It will be noticed that in these architectural changes in institu- 
tions there has been a steady development away from the linear 



DEVELOPMENT OF HOSPITAL ARCHITECTURE 213 

form of hospital construction. In most of the colony cottages, 
arrangements are made for dormitories on the second floor and for 
day rooms, sitting rooms and service rooms upon the first floor. 
Many of the buildings are complete, with kitchen, dining rooms 
and work rooms, and the work of the house is done by patients. 

At Central Islip, N. Y., there is a similar development of 
isolated buildings for the accommodation of chronic patients who 
are able to employ themselves in useful labor. The organization 
seems to be semi-military, the patients going to labor at definite 
hours, and returning at the stroke of the bell. They march to a 
central dining room at a definite time and return to labor at a 
fixed hour. Through the labor of patients an uninteresting and 
unproductive tract of ground has been made to blossom and to 
produce large returns. The institution has developed out-door 
industries, probably to a greater extent than any other, and while 
the buildings are not upon the group plan, they are so arranged as 
to make an effective separation of patients. 

In Kansas the colony system of caring for the insane has been 
incorporated into the general law and the same thing is true in 
Colorado. The most elaborate of the newly erected institutions 
on the cottage plan are probably to be found in Indiana, where 
two institutions, the Eastern and the Southeastern, have been built 
in this manner. 

It is evident that for many years to come provision for the 
insane in the United States will take this form rather than that 
originally laid down in the " propositions." 



CHAPTER VI 

DEVELOPMENT AND EXTENSION OF 
METHODS OF TREATMENT 



I. 

THE PROPOSITIONS. 

A brief consideration of the " propositions " seems essential to a 
proper understanding" of the manner in which the older superin- 
tendents viewed their work and responsibilities. It must be 
remembered that the majority of the superintendents, if not all, 
who assumed charge of institutions for the insane at first were 
engaged in a new and untried work. They had strong convictions 
as to what should be done and were fearful that mistakes might be 
made by those who sought to establish institutions in newly devel- 
oping pioneer communities. Although they had as a rule the sup- 
port of an enlightened public sentiment, more especially of the 
medical profession, they realized that they owed a duty to the 
public to lay down certain fixed principles for future guidance. 
The object of the " propositions " undoubtedly has been misunder- 
stood by many critics, because it has been interpreted in the light of 
our present knowledge. We know now, after years of experience, 
that the views of the older men w^ere too hard and fast, and their 
" propositions " as originally expressed lacked sufficient elasticity 
to adapt themselves to changing conditions, created largely by the 
error of earlier views as to the curability of insanity. It is unques- 
tionable, however, that the "propositions " were necessary at the 
time they were written to secure the proper construction and 
organization of such an institution as was contemplated by the 
earlier men who engaged in the treatment of insanity. The suc- 
cess of the hospital then depended largely upon the personal labors 
of the superintendent who was, as I have indicated in another place, 
not only superintendent, steward and medical expert, but also sole 
physician. Under such an organization it is not strange that it 
was thought essential to keep the number of patients small, so that 
each one might have the personal care and supervision of the 
superintendent. 

The first " proposition " enunciated at the first meeting of the 
Association in 1844 related to personal restraint of the insane. The 
last " proposition," giving expression to the views of the Associa- 
tion as to proper provision for inebriates, was adopted in 1875. 
21 



2l8 INSTITUTIONAL CARE OF THE INSANE 

During the intervening 30 years many declarations of opinion were 
placed in the minutes of the Association, all of which were useful 
and the majority of them most timely and necessary. 

In following the history of the Association careful consideration 
must be given to the import of the " propositions." They were the 
deliberate utterances of the leading minds of a body of men 
personally engaged in the care of the insane, and in every instance 
they represented conclusions which had been reached after much 
thought and no little experience. The declarations were not in any 
sense doctrinaire theories evolved in the study, but were the 
results of experience and reasoned conviction. The persons who 
originally engaged in the treatment of insanity in the United 
States, although not experts in the work, were none the less capa- 
ble physicians and philanthropic and sagacious men who felt it to 
be their duty, while they were exploring a hitherto unknown 
region, to leave behind them a blazed trail to guide those who 
should come after. They had no thought that they had acquired 
all knowledge attainable upon the subject and had reached ulti- 
mate conclusions, but they were impressed with the fact that they 
had found some methods preferable to others and these methods 
they gave to the world. 

The declaration in 1844 at the first meeting of the Association 
that " it is the unanimous sense of this convention that the attempt 
to abandon entirely the use of all means of personal restraint is 
not sanctioned by the true interests of the insane," undoubtedly 
represented the settled convictions of the greater part of those who 
were caring for the insane at that date. There lingered in the 
minds of all a trace of the old traditions that the insane had a 
degree of perversity which required corrective measures. Rush 
still dominated the medical world and his views as to the necessity 
of breaking the wills of patients were familiar to all and were 
generally accepted. It is probable also that the sternness which 
characterized New England family life had something to do with 
the feeling that restraint and correction were essential to proper 
care and cure. The moderation of the declaration is more sur- 
prising than the mere sentiment ; it indicates the existence of a 
conviction that personal restraint is not a blessing and seems in 
marked contrast to the sentiments enunciated by members of the 
Association a quarter century later. 



THE PROPOSITIONS 219 

The " propositions " which were formulated for the construction 
of hospitals for the insane were perhaps the most important and 
far-reaching in their influence. They provided in brief that every 
hospital should be in the country not less than two miles from a 
large town and easily accessible at all times, upon a site containing 
not less than 50 acres of land devoted to gardens and pleasure 
grounds, and, if a state hospital of 200 patients, comprising not less 
than 200 acres ; that at least 10,000 gallons of water should be sup- 
plied daily to reservoirs commanding the highest portions of the 
buildings ; that no hospital should be built without the submission 
of the plans for approval to a physician or physicians who have had 
practical experience in a similar establishment ; that not more than 
250, and preferably 200, patients should be placed in one building ; 
that the buildings should be constructed of stone or brick, wnth 
slate or metallic roofs, with ample and accessible stairways of iron, 
stone or other indestructible material to afford egress in case of 
fire ; that every hospital should have at least eight distinct wards 
for each sex, each ward with a parlor, corridor, single bed-rooms, 
associate dormitory, clothes-room, bath-room, water closet, dining 
room, dumb waiter and speaking tube communicating with the 
kitchen ; that all rooms for patients should be above ground not 
less than eight by ten feet, with ceiling at least 12 feet in height, 
with outside windows, and floors of wood ; that there should be a 
central building for offices, living rooms for officers and others 
and separate wings for each sex ; that the lighting should be by 
gas ; that the laundry should be in a detached building ; that there 
should be sewers, steam or hot water heating and forced ventila- 
tion ; that all boilers for steam power should be in detached build- 
ings; that water closets should be of indestructible materials and 
ventilated and their floors of non-absorbent material; that the 
rooms of wards for the most excited also should be on one side 
of the corridor at least ten feet in width with external windows 
affording pleasant views, and, finally, that the pleasure grounds 
should be surrounded by a wall. 

The " propositions " in regard to buildings were not the final 
word in the matter, as all will concede, but they initiated an era 
of better buildings and prepared the way for more hygienic sur- 
roundings for the insane. The economy practised in such plain, 
substantial structures unquestionably had a favorable influence 
upon the building of similar institutions in pioneer states. 



220 INSTITUTIONAL CARE OF THE INSANE 

The limitation of the capacity of proposed hospitals to 250 beds 
for patients, as adopted " unanimously " in 185 1, was extended, by 
a vote of nine to five, to a permissible accommodation of 600 in 
1866. 

Respecting- the " legal relations "of the insane, Dr. Ray's elabo- 
rate " project of a law " is memorable only because of one or two 
features. The first providing for the appointment, by judges, of 
juries composed entirely of physicans, one of whom, for each 
jury, if practicable, shall be an expert in insanity, to settle the 
question of the mental competency for trial of persons accused of 
crime, but pleading insanity as an excuse ; and the second, making 
it obligatory on the part of the prosecution to prove that the 
criminal acts of an insane person on trial for crime were not the 
result of insanity, direct or indirect, in order to establish any degree 
of responsibility for such acts. 

The Association disapproved of the admission of insane crim- 
inals or of inebriates to hospitals occupied by other classes of 
insane persons ; but urgently recommended public provision for 
them both as separate classes. 

In 1853 ^ similar elaborate series of " propositions " in relation 
to the organization of hospitals for the insane was prepared by 
Dr. Kirkbride. They were also most useful and timely and have 
accomplished much good. Their usefulness in fact has not yet 
ceased. Those who read them can readily understand how greatly 
these clear-cut and well-considered phrases influenced persons who 
were about to organize new institutions. 

In 1866 elaborate and carefully framed resolutions were adopted 
in regard to the care of the several classes of insane. These prin- 
ciples still govern public policy in the majority of the United States 
to-day, which fact attests the validity of the sentiment therein 
expressed. 

In 1871 a series of " propositions " involving a project of a law 
to control the legal relations of the insane was adopted. 

The " propositions " in reference to the construction and organi- 
zation of hospitals was undoubtedly the work of Dr. Kirkbride ; 
the " propositions " as to the legal relations of the insane and the 
project of a law were framed by Dr. Isaac Ray. 

It had been evident, however, for many years prior to 1875 that 
the needs of the country had outgrown the special form of hospital 



THE PROPOSITIONS 221 

accommodations which had been deemed ample in its earlier his- 
tory. It was also equally apparent that the older men who fathered 
the original scheme had grown to regard it as the only proper 
method of caring for the insane. Such mistakes are often made by 
elderly men who seek in vain to arrange the world and to set it in 
order for all future time. 

Animated debates over the " propositions " occurred in succes- 
sive meetings of the Association and more or less personal feeling 
was generated between the younger and older members. The latter 
worshipped the " propositions " with a deep and fervent venera- 
tion and seemed to regard them as sacred, while the former be- 
lieved them to be outgrown and no longer necessary. The weight 
of argument v/as clearly with the younger members, because, 
notwithstanding the prohibition of institutions beyond 250 patients, 
many institutions were already accommodating 1000 or 1200 per- 
sons. The author of the " propositions " even had been compelled 
to extend the Pennsylvania Hospital far beyond the original num- 
ber by the construction of an entirely new department under his 
own control, but nominally supervised by an assistant physician. 
The need of care for insane patients, however, had become so great 
in rapidly growing states it was impossible to limit the numbers 
of any institution or even to predict the extent to which they might 
eventually be increased. 

In the year 1888, at a meeting of the Association at Old Point 
Comfort, an elaborate report signed by Dr. Orpheus Everts and 
Dr. Foster Pratt was presented, which gave rise to an animated 
debate, characterized by considerable plainness of speech on the 
part of the friends and opponents of the " propositions." The 
committee recommended that economy, humanity and the wisdom 
of experience suggested the propriety of the separation of classes 
of patients and different provision for them, such as hospitals 
for acute and active insanity, asylums and homes for the class 
permanently impaired by disease and training schools for the edu- 
cation and training of those naturally defective. The committee 
recommended a departure from the former method of constructing 
all institutions upon one plan and suggested that they should be 
divided into small wards especially adapted to the needs of acute 
forms of disease. They should be fireproof, tasteful and attractive 
in appearance. The asylum proper or home for incurable patients 



222 INSTITUTIONAL CARE OF THE INSANE 

should be furnished more with reference to daily use and con- 
structed comfortably, spaciously and economically, with a view to 
utilize the energies of chronic patients in useful employment. 

Buildings for the custody and treatment of insane criminals 
should embrace hospital, asylum and prison features combined. 

In the matter of organization of the hospital and asylum the 
report did not deviate materially from the original " propositions," 
but entered more into detail as to the character of boards of 
trustees and the qualifications of superintendents of institutions 
and their tenure of office. 

For the care and treatment of the insane there could be no 
inelastic system or prescribed rules. The committee was strongly 
in favor of individualized treatment and the special study of insan- 
ity to ascertain its cause and the best methods of prevention. 

In the matter of the legal relations of the insane the report of 
the committee was extremely sensible. It proceeded upon the 
assumption that all insane persons should be considered wards of 
the courts and that the legal status of insane criminals under the 
law should be that of minors who are not fully responsible for their 
actions. The committee did not believe in the doctrine that the 
presence of any and each degree of mental impairment might be an 
unconditional excuse for any crime, but thought that in all legal 
proceedings, when insanity is pleaded as an excuse for crime, the 
degree of mental impairment should be considered. 

Such in substance were the changes in the " propositions " con- 
templated by the committee. The report in the light of present 
views does not seem contrary to the general principles already 
established. It met, however, active opposition and was debated 
with much warmth of feeling. Finally, it was decided by a small 
majority that in the judgment of the Association there was no 
necessity of reaffirming the original " propositions." A second 
resolution was added that it was inexpedient to adopt any new 
" propositions." These two resolutions seem to indicate that the 
life of the " propositions " had departed. A resolution was subse- 
quently adopted asking the chairman of the committee to present 
his views personally at the next meeting of the Association, but 
nothing came of it and during the past 25 years no effort has been 
made to reopen the question, either by repealing or reaffirming any 
of the existing " propositions." 



II. 

REFORMS IN CARING FOR THE INSANE. 

It is interesting to note that while the humanitarian sentiment 
of the whole country favored the treatment of the insane in well- 
organized institutions, constructed according to advanced ideas, 
as to individual air-space, pleasantness of situation, abundance of 
ventilation and efficient heating, so that in fact the early buildings 
for the insane were in most instances far superior in site, ventila- 
tion and heating to schoolhouses, churches, colleges and even gen- 
eral hospitals, yet no great pains were taken to study questions 
which affected the personal comfort of the patients placed in such 
exceptionally well-arranged and well-designed institutions. This 
was due largely to the fact that philanthropists and others inter- 
ested in the proper housing of the insane failed to appreciate a 
most important truth in reference to insanity : that the violent, 
destructive and often dangerous tendencies of the insane were a 
part of their disease and not a manifestation of perversity requir- 
ing forms of restraint often deteriorating into punishment. 

Up to the year 1880 patients were subjected to direct and indirect 
mechanical restraint. They were placed in cells, the fixtures of 
which were generally so arranged as to render it comparatively 
easy to neglect those who occupied them, and were often deprived 
of the ordinary comforts of life. If the insane destroyed clothing, 
they were left without it ; if they broke up furniture it was taken 
away ; if they declined to lie upon beds, the floor was supposed to 
provide ample accommodations for them. The same laissez-faire 
theory characterized the provision made to give patients exercise 
in the open air. They were placed in airing courts surrounded by 
high walls, which were more like places of confinement than 
grounds designed to promote comfort, diversion or active exercise. 
These airing courts were doubtless better than the ordinary cell, 
but, except for the fact that they were in the open, they suffered 
under much the same limitations as the smaller, darker and less 
ventilated cells of the institution. There was little in their arrange- 
ment and outlook which suggested any change of scene to the 
patient oppressed by morbid thoughts, nor were they calculated to 



224 INSTITUTIONAL CARE OF THE INSANE 

promote his self-respect or self-control. This, however, was not 
the worst of the difficulties which were encountered in the care of 
the insane. In many instances insane patients were destructive to 
clothing and to furniture or were violent and insulting in their 
relations to those who had them in charge as nurses or attendants. 
It is interesting to observe how the older writers among the super- 
intendents of institutions theorized as to the remedies for this state 
of aflfairs. They argue that, as insane persons were irresponsible 
and incapable of self-control, it was necessary that they should be 
restrained by mechanical means until such time as reason and self- 
control reasserted themselves. Hence it became customary to use 
mechanical restraint in almost every case characterized by excite- 
ment. In the literature of insanity it began to be stated as an 
axiom that, as insane patients were unable to control themselves, 
it was the duty of the medical officer to see that they were con- 
trolled. In other instances mechanical restraint was employed to 
prevent suicidal as well as homicidal attempts. It was not uncom- 
mon for a suicidal patient to be placed in mechanical restraint by 
day and by night. 

Motives of economy also seemed to encourage the use of 
mechanical restraint because of the expense incident to the destruc- 
tive tendencies of patients. A certain amount of mechanical 
restraint was thought necessary to save the institution a large out- 
lay for bedding, clothing, furniture and the like which would other- 
wise be needed to replace articles destroyed by excited patients. It 
was honestly believed that mechanical restraint was less irritating 
and annoying than personal control at the hands of stalwart attend- 
ants, because easily understood by insane patients to be neces- 
sitated by their destructive tendencies. This may have been true 
to a certain extent, but the whole theory of restraint was based 
upon a fallacy which later on, when attempts were made to do 
away with it, became self-evident. The fact that a patient made 
a homicidal attack, or was destructive, or dangerous, or suicidal, 
did not necessarily imply that, unless he was continuously re- 
strained, he would be continuously suicidal, destructive or homici- 
dal. That these acts were not due to irresistible impulses, but were 
passing phases of a long-continuing disease, was often overlooked 
by those who had the care of such patients. During the era of 
restraint it was customary to see patients restrained, secluded or 



REFORMS IN CARING FOR THE INSANE 225 

in solitary confinement for weeks, months, and even years. The 
explanation of such treatment often given by physicians and nurses 
was that the patient required restraint because of some previous 
act of violence, but in some instances these acts were so far in the 
past as to become matters of tradition. Although he might have 
committed no violent acts during the period of restraint, it was, 
nevertheless, firmly believed that he would have committed them 
had be been at liberty, and hence he was regarded as still danger- 
ous to himself or others and still in need of continuous restraint. 

When mechanical restraint was finally removed in consequence 
of the growing reform of methods it became apparent that its 
application in the majority of cases had developed and rendered 
continuously active the very tendencies which it had originally been 
designed to remove. Patients because of restraint had become 
violent, morose, moody, revengeful, destructive to clothing, untidy 
and in many respects most disagreeable. As a matter of fact, 
when non-restraint was generally adopted in the United States it 
was found that many institutions were filled with a dangerous, 
destructive, degraded and violent class of chronic cases which was 
not found abroad and which no longer existed, indeed, in institu- 
tions where methods of non-restraint had been practised for a few 
years. Restraint had tended to perpetuate acts of violence and 
destructive habits and had so aggravated them as to create a dis- 
tinct class of violent patients in every hospital. The remedy had 
plainly been worse than the disease. Under the restraint system 
many patients had passed their lives in restraint and seclusion 
with little or no effort to provide them with employment, out-of- 
door exercise, proper amusement, or to introduce into their lives 
any influence calculated to divert them from morbid fancies or 
supply an active, healthy outlet for normal energies. 

The question of the comparative wisdom of restraint and non- 
restraint was frequently brought to the attention of members of 
the Association by the criticisms made by visitors from abroad, 
who were familiar with non-restraint methods in English insti- 
tutions. From 1850 to 1880 scarcely a session of the older Asso- 
ciation of Superintendents of Institutions for the Insane was held 
that the matter was not debated. It is evident that the attitude 
assumed by the majority of superintendents was in favor of 
restraint, although an occasional voice was lifted against it. 



226 INSTITUTIONAL CARE OF THE INSANE 

One of the earliest advocates of the non-restraint method of 
caring- for patients was Dr. Richard Giindry, of Ohio, who had 
inaugurated the system in the Athens State Hospital, of which he 
was superintendent at that time. The most earnest advocate of 
restraint was probably Dr. John P. Gray, a forceful and influential 
man, then superintendent of the Utica State Hospital. He believed 
that restraint was essential not only to the comfort and recovery of 
patients incapable of self-control, but in the case of those suffer- 
ing from acute and debilitating forms of mental derangement, 
who were exhausting themselves by unrestrained movements and 
extravagant actions, and he regarded it the duty of every superin- 
tendent to prevent this tendency to exhaustion, as far as possible, 
by keeping all violent or excited patients forcibly in bed. In pur- 
suance of this idea feeble patients in some institutions were pre- 
vented from getting out of bed at night, or exposing themselves 
during severe weather by day, by placing them in covered beds 
where they could not assume even a sitting posture. At one time 
the so-called " Utica crib " was highly praised and regarded as of 
great service. It is now remembered that, no matter how many 
beds of this kind had been provided for a given institution, all of 
them were in use and all seemed necessary. The presence of the 
covered bed led to its use. Later on, owing to the spread of non- 
restraint methods and just criticisms upon this form of restraint, 
it was found that patients did not exhaust themselves by sleeping 
in open beds, nor were they more liable to injury or disease than 
when under conditions of restraint. 

About the year 1880, largely as a result of observations made by 
superintendents who had visited institutions in England and Scot- 
land or upon the Continent, there developed a strong feeling that 
in the matter of restraint the institutions of the United States and 
Canada had fallen behind the methods employed in the older coun- 
tries. 

Visitors to European countries who inspected institutions saw 
comparatively few cases with violent or destructive propensities. 
Various somewhat amusing explanations were given of the greater 
quietness of patients in England and Scotland as compared with 
America. The most common one was that the American, being an 
independent citizen, a sovereign in his own country, with a belief 
that no one had any right to place him in confinement or to abridge 



REFORMS IN CARING FOR THE INSANE 22/ 

his freedom of action, very naturally resented all control. Another 
popular theory was that the greater violence and destructiveness of 
patients in America was due to the presence of large numbers of 
insane foreigners, who had not been accustomed to liberty and who 
regarded it as license rather than enlightened freedom. I remem- 
ber one instance cited in confirmation of this theory, that of an 
Irish patient in an English institution, who, when he first came 
under treatment directly from Ireland, was quiet, well-behaved and 
amenable to treatment. Later, however, when he returned to the 
English institution after a residence in America, he was found 
to be a violent, dangerous and altogether undesirable patient. 
Such was the reputed effect of free institutions. The more stimu- 
lating quality of the climate of the United States was also assigned 
as the cause of more frequent acts of frenzied violence. 

Both in Canada and the United States sporadic attempts had 
been made at an earlier date to dispense with restraint, oftentimes, 
unfortunately, without adequately educating the officers and at- 
tendants of institutions in the principles underlying the new 
regime. The effect of these ill-considered efforts had been to dis- 
courage those who had the immediate care of patients and to 
convert hitherto quiet, comfortable wards into scenes of great dis- 
order and confusion. These unfortunate results were due largely 
to the fact that those who attempted the reform failed to appreci- 
ate that a simple removal of restraint was not enough and that the 
patient thus released must have some active outlet for his energies. 
Hence it was essential that occupations suited to his mental condi- 
tion, especially those carried on in the open air, should be provided, 
in order to change his mental attitude and to furnish a substitute 
for the control from which he had been released. 

Wherever non-restraint was adopted carefully and judiciously 
it promoted the comfort and well-being of the patient. But where 
non-restraint was simply decreed, without any plan to furnish a 
substitute for it, it was found that the relations between patient 
and nurse became extremely unpleasant. The nurse forbidden to 
use mechanical restraint sometimes resorted to force and intimida- 
tion, which terminated in personal collisions between the patient 
and his nurses. Not a few of the earlier attempts at non-restraint 
failed because of this failure to devise occupation for the patients. 



228 INSTITUTIONAL CARE OF THE INSANE 

During the past quarter of a century non-restraint has made its 
way generally throughout the United States. In some states, as 
in Massachusetts, it has become a matter of state policy, mechanical 
restraint, unless under exceptional conditions, being forbidden by 
law. The effort has been to substitute nursing and kind personal 
care for mechanical restraint and intimidation. The nurses, not 
being allowed to penalize the patient by confining his hands, or 
feet, or person, must contrive to get along with him. In order to 
effect this they first make friends with him and show themselves to 
be nurses and not keepers. It soon became evident to all who had 
personal care of the insane that nurses should be helped to devise 
methods of employment for the energies of patients who were no 
longer in restraint and seclusion ; hence among female patients 
there followed a great development of household industries. 
Patients were encouraged to assist in the laundry, in the sewing 
room and mending room, as well as to engage in fancy work, braid- 
ing rugs, rug-making, carpet weaving and a thousand and one 
feminine occupations. Among the male patients it was found 
desirable, in the majority of cases, to devise out-of-door occu- 
pations in the form of wheel-barrow work, the care of cattle, the 
cultivation of the ground, cutting wood, hauling coal, etc. Those 
who were unable to engage in employment of this kind or were not 
accustomed to out-door work found excellent occupation in shoe- 
making, brush-making and similar minor industries. The effect 
of this change has been to improve the condition of the insane in 
the United States to a remarkable degree. Violent, destructive and 
outrageous patients are now the exception, where formerly they 
were the rule. 

Careful inspection of institutions in the United States and 
Canada, as compared with those abroad, shows that insane patients 
in America do not differ very materially from those found abroad. 
The change of type and the exaggeration of unpleasant character- 
istics, so learnedly commented upon by early writers and visitors, 
are now generally agreed to have been due to faulty methods of 
control, which aggravated and did not cure the condition. 

The disuse of restraint upon a large scale was first attempted in 
Canada by Dr. R. M. Bucke. The next important step in doing 
away with restraint was taken in Michigan, where, in the course of 
a few months, the system which had been common in all the state 



REFORMS IN CARING FOR THE INSANE 229 

institutions was gradually and quietly relinquished, to the manifest 
improvement of the condition of the patient. 

Similar movements soon follow^ed in New York, Massachusetts, 
Ohio and many other states, until, at the present writing, there are 
comparatively few states where mechanical restraint is employed. 

In Massachusetts Dr. C. W. Page, for many years superin- 
tendent of the Danvers State Hospital, gave much careful attention 
to the matter and developed a public sentiment which has found 
expression within the past two years in an act passed by the State 
Legislature forbidding restraint except under special and unusual 
conditions. 

The abolition of restraint, as previously stated, would have been 
impracticable and unwise had it not been for the development of 
industries, the abolition of airing courts and the destruction of 
restraining apparatus. In one state, under a new superintendent, 
a dramatic destruction of restraining apparatus took place upon a 
holiday, when, in the presence of the patients, after a prayer from 
a clergyman and an oration from a politician, two wagon loads of 
restraining apparatus were burned. In other institutions, while 
there was probably less demonstration, the abolition of restraint 
was equally effective. 



III. 

MEDICAL TREATMENT OF THE INSANE. 

It is interesting to notice in the early history of institutions 
how much attention was paid to medication ; almost every insti- 
tution had formulae, each containing many medical ingredients for 
various forms of insanity. Certain remedies were used in excite- 
ment, others in depression, others in dementia, etc. One of the 
most interesting aspects of the treatment of patients, the original 
idea being derived from Benjamin Rush, was that maniacal excite- 
ment required blood letting. At the time of the opening of the 
Hartford Retreat, the Worcester State Hospital, and even the 
Utica State Hospital, nearly 20 years later, it was found that all 
patients who came to the institutions suffering from maniacal 
excitement had been subjected to repeated blood letting. It was 
also evident that while the immediate effect of the operation had 
been to quiet the patients, the after-effects of it were to destroy 
every chance of recovery. This was later shown by Dr. Earle in a 
series of observations, both in this country and Europe, to which 
reference has already been made. 

There are few records of bleeding in connection with hospital 
care, and the practice seems to have been very generally discon- 
tinued in institutions. In place of it, however, sedatives were 
given, especially in connection with excitement, as well as emetics 
and sometimes very active cathartics. Reliance was also placed 
upon calomel or blue pills, Dover's powder with quinine, ipecac, 
tartrate of antimony or some other very active heart remedy. 
Digitalis, hyoscyamus, camphor and the preparations of opium 
were also given. 

In a number of the meetings of the Association there was much 
discussion and a pretty general unanimity of opinion that certain 
remedies were to be used in excitement, as, for example, etheriza- 
tion to control maniacal excitement, or opium to relieve the un- 
pleasant phenomena of depression. Most of the patients were kept 
under more or less constant medical treatment which generally 
took the form of tonic remedies calculated to improve the appetite 
and the general nutrition. 



MEDICAL TREATMENT OF THE INSANE 23 1 

Dr. Edward Cowles/ in a paper printed 20 years ago, says : 

These teachings of Rush long controlled the treatment of insanity by 
general practitioners in America. But these depletory and reducing means 
were practically discarded by the earlier alienists who came after Rush. 
The Frankford Asylum, opened in 1817, employed the mild methods of the 
York Retreat in England, and exercised a most salutary influence by its 
example. At the McLean Asylum in 1818 Dr. Wyman adopted the system 
of Pinel and Tuke, and was opposed to depletory treatment ; and Dr. Bell 
in 1841 wrote that "the practice of bleeding, violent purgation, emetics, 
vesications and derivations has passed away before the light of experience." 
In the earlier years of the Hartford Retreat, which was built in 1824, Dr. 
Todd insisted upon generous diet, and recommended a frequent resort to 
tonics and narcotics in the medical treatment of the insane. He found that 
it required considerable boldness and address to introduce this plan of treat- 
ment, contrary to the teachings of Rush. These rational views were 
advocated by Brigham, Ray. Bell, Kirkbride, Curwen, and many others. 
But Earle, as late as 1854, found occasion for a strong protest against the 
general practice of blood-letting in insanity as an error then generally 
prevalent. 

The practical therapeutics of that time, from 1840 to 1850, may be summed 
up, truthfully perhaps, as follows, both for England and America: With 
the discarding of the theories of inflammation and depletion as the prime 
indications in insanity, the practice of a " supporting treatment " had come 
into favor, with medication aimed at meeting the symptoms as they 
appeared. About 1840 it was, with many, the rule of practice to regard it 
as an important first indication to meet the symptoms of local congestion, 
especially when there was evident determination of blood to the brain. But 
in the treatment of this condition only local bleeding was approved in the 
best hospitals, and that under many cautions against exhaustion or col- 
lapse. Emetics were regarded as useful in torpid states, as in melancholia 
with dyspeptic disorder. The best method was to use tartrate of antimony, 
which was found most efficient often in mania. But care was to be taken 
not to be misled by the calmness thus produced, which arises from 
exhaustion. 

Purgatives, laxatives and enemata were used with much of the careful 
discrimination taught by modern therapeutics, the less drastic remedies 
being best approved. Preparations of mercury were used with more care 
than before that time. Opium, narcotics and sedatives were in general use ; 
these included hyoscyamus, belladonna and conium. They were used to 
allay excitement or agitation or as hypnotics. Opium and morphia, while 
their use was regarded as requiring discrimination, were believed to be 
liable to cause phrenitis in cases of cerebral congestion and great vascular 
action. When indicated, opium was given in large doses ; but it was often 
contraindicated for sleeplessness, if after taking it the patient should 
awake with increased excitement. Camphor was much used, and often 

* American Journal of Insanity, Vol. 51, p. 15. 



232 INSTITUTIONAL CARE OF THE INSANE 

combined with liquor ammonise acetatis, and was regarded as a valuable 
remedy. 

Counter irritation was still prescribed to some extent. It is to be pre- 
sumed that some in America followed an English authority of the time, 
and regarded blisters as beneficial in mania as revulsives, and as useful in 
melancholia by their irritation serving to divert the mind from its morbid 
train of thought. It was considered injurious to apply them to the head, 
as they increased the excitement of the cerebral membranes and interfered 
with the application of cold. Tartar emetic ointment and the like were 
used to maintain a steady counter irritation on the back of the neck in 
recent cases of insanity. Cold to the head, the douche for the same pur- 
pose, the warm bath with friction of the lower extremities, were prescribed 
in appropriate cases. But the use of cold water was regarded as requiring 
caution, and unjustifiable as a mode of punishment. 

In the search for data as to the practice of American alienists in the use 
of medicine during the last half-century, the case-records for 75 years of 
the McLean Asylum have furnished a mine of information. The general 
results of their examination in detail will be given here, as probably afford- 
ing a fair example of American practice and showing the changes in it. 

In the period from 1840 to 1850 these records confirm the indications of 
the foregoing summary of the therapeutics of the time, except that there is 
proof, by negative evidence, of Dr. Bell's statement, already quoted, as to 
the disuse of "violent derivations." Tartar emetic ointment, applied to the 
spine, is once mentioned. A common tonic was " red mixture " (conium and 
carbonate of iron). Quinine, arsenic, port wine, "brandy and bark" were 
prescribed. Chloric ether was sometimes given in agitated melancholia. 
Tincture of opium in one drachm to three drachm doses was prescribed for 
the excitement of mania and sometimes in melancholia. It is noted in a 
case of puerperal insanity that " a previous attack seven years before had 
doubtless been prolonged by depletory treatment — bleeding, blistering, 
salivation and starvation." It is interesting to note the use, in a number 
of cases, of inhalations of ether and chloroform to allay excitement and 
promote sleep. " Supporting treatment," with nutritious and liberal diet, 
was the regular practice. The writer recalls with interest his personal 
experience in the preparing and dispensing, as a junior officer at the Hart- 
ford Retreat, about i860, of a very similar list of medicines. The terms 
"red mixture," "elixir pro" and " nux and gentian" are vividly remem- 
bered, as well as the consistent teaching and practice of the " supporting 
treatment." 

Moral treatment was regarded in all the asylums as of the greatest value. 
Taking the practice of the McLean Asylum as an example of the views 
prevalent from its beginning, in 1818, to 1850, its records show that great 
attention was paid to occupation and recreation. Dr. Bell gave interesting 
accounts in his reports of the means for inducing patients to take exercise, 
in manual labor on the farm and in the carpenter's shop, walking in the 
gardens, excursions, in-door games, entertainments, etc. These methods 
were not unlike those employed in hospitals of the same class at the present 
day. 



MEDICAL TREATMENT OF THE INSANE 233 

At the McLean Asylum, up to about 1865, there is little change noted 
in the records beyond the introduction of new preparations of iron, the 
occasional use of strychnia, etc. But in that year bromide of potassium 
appears as being prescribed for melancholia. The use of opium and 
morphia at that time had notably diminished to small doses, often com- 
bined with hyoscyamus ; and these prescriptions were much less frequent. 
Chloral hydrate appears among the drugs given in 1871 ; but before 1890 
this and the bromides were practically no longer prescribed. Cannabis 
indica was given for a time, about 1880, but was quite abandoned, along 
with all preparations of opium, except codein, which was used in the rest- 
lessness of elderly people to allay distress, and in some cases of melancholia. 
During the latter period the newer preparations of iron, quinine, strychnia, 
etc., were commonly given. A rather increased use of stimulants at one 
time yielded to the more common practice of frequent feeding, especially 
at night. 

The therapeutic history of the last five years or more of this hospital 
shows an extension of the indications just noted; there was also a marked 
lessening of the use of hypnotics. Paraldehyd and urethane were not long 
used. Sulfonal then came in vogue, but after three or four years was 
practically disused as unsatisfactory because of its possible after-effects; it 
still appears to be used in many hospitals, but there is evidence, in cases 
that come to them, that this and other like drugs are employed to excess. 
Then came chloralamid and trional, and these last are still prescribed for 
brief periods in severe cases. Hyoscyamin and the like were never used 
here beyond a few experimental doses. The same is true of hyoscin, 
although it is perhaps generally regarded as a useful drug. But gradually 
the practice has come to be the dependence upon food as the best tonic, 
and the best hypnotic, frequent feeding by night-nurses, with the warm 
bath as an adjuvant. A few sleepless nights were not regarded with 
anxiety, nor even a long continuance of small amounts of sleep nightly, as 
long as nutrition is maintained, as it more surely is when no poisons are 
given that impair the digestion and aggravate irritation by their after- 
effects. 

After 1880 there was noted the increasingly diligent use of massage, 
sometimes faradism, and gentle g>-mnastics, with increasing amounts of 
exercise as it was borne. Absolute rest in bed in appropriate cases was 
prescribed, except when unendurable because of distressing restlessness ; 
but such rest was insisted upon, and modified to suit the case — till after 
midday, or after breakfast. The practice of this later period may be 
summed up as the further development of the " supporting treatment " 
that our fathers began early in the century. 



IV. 

NON-MEDICAL TREATMENT OF THE INSANE. 

It seems appropriate in this connection to make full mention of 
Brigham's views in reference to what he termed the moral treat- 
ment of the insane, that is, their treatment by measures other than 
medical/ 

He dissents absolutely from the directions given by Dr. Rush ^ as 
to the care of the insane and says that they cannot be a correct 
guide. In his opinion a prevailing error in Rush's views is the 
belief that those in charge of the insane must obtain control over 
them by fear or by other equally improper means. Rush says, for 
example, " the first object of a physician when he enters a cell or 
chamber of the average person should be to catch his eye and 
look him out of countenance." Again, " the conduct of a physician 
should be uniformly dignified to his patients, if he wishes to 
acquire their obedience and respect. He should never descend to 
levity in conversing with them. He should hear with silence their 
rudeness or witty answers to his questions and upon no account 
ever to laugh at them or with them." After enumerating the 
various means for making insane persons obedient, Rush con- 
tinues : " If these prove inefifectual to establish a government over 
deranged persons, recourse should be had to certain modes of 
coercion." 

It is interesting to notice that among the methods of coercion are 
the straight waistcoat, the tranquilizing chair, the deprivation of 
customary pleasant food and pouring cold water under the coat 
sleeve so that it may descend to the arm pits. If these methods fail 
of the intended effect, Rush regarded it as " proper to resort to the 
fear of death." 

With these views Brigham entirely disagrees, and he quotes with 
great approval the remarks of Dr. Wyman, the first physician and 
superintendent of the McLean Asylum, as follows: " In mental 
disorders where there are no symptoms of organic disease a 

* Moral Treatment of Insanity, Am. Jour. Insanity, p. i, Vol. 4, 1847. 
' Observations on Diseases of the Mind. 



NON-MEDICAL TREATMENT OF THE INSANE 235 

judicious moral management is most successful." This moral 
management " should engage the mind and exercise the body ; as in 
riding, walking, sewing, embroidery, bowling, gardening and the 
mechanical arts, to which may be added reading, writing, con- 
versation, etc. The whole to be performed with order and regu- 
larity." He says that " even the taking of food, retiring to bed, 
rising in the morning at stated times, and conforming to stated 
rules in almost everything, is a salutary discipline." 

Some ten years before Dr. Todd, of Hartford, to use his own 
words, made " the law of kindness the all-pervading power of the 
moral discipline of the Retreat and required unvaried gentleness 
and respect to be manifested towards the inmates of the institution 
by every member belonging to it." This course of treatment was 
wholly opposed to the recommendations of Rush, and Todd 
showed much skill and tact in securing its general recognition in 
this country. 

Brigham regarded bodily labor as one of the measures neces- 
sary for the moral treatment of the insane and in the article 
mentioned above he expresses the hope that in the future, arrange- 
ments will be made by which the inmates of insane institutions 
will be better able to avail themselves of this means of cure. He 
laments the fact that some institutions at that time had insufficient 
land and no work-shops and states his belief that every institution 
should have a good farm attached to it, which alone, however, he 
considered was not sufficient. He thought that work-shops also 
should be connected with even,- institution, in which dress-making, 
tailoring, basket-making, shoe-making, painting, printing, book- 
binding and other employments might be carried on by patients 
who could not be employed on a farm. But though he believed 
bodily labor to be useful, he regarded it as less curative than men- 
tal occupation. Manual labor he considered beneficial because it 
engages the attention and directs the mind to new objects of 
thought, but he feared that in some instances, especially in con- 
valescence from acute disease, it might do harm and produce 
mental excitement. He believed that manual labor was most 
useful with incurable patients, since by preserving the health and 
arresting the tendency to mental impairment it rendered their 
condition more comfortable. With curable patients, on the other 
hand, he considered mental occupation more beneficial, especially 



236 INSTITUTIONAL CARE OF THE INSANE 

employing the mind in pursuits which engaged the attention, sug- 
gested new objects of thought, and enlarged and improved both 
the mental and moral powers. 

Institutions, he thought, should be supplied with books, maps, 
scientific apparatus and collections in natural history. Schools 
should be established in every institution, w'here patients could 
learn reading, writing, drawing, music, arithmetic, geography, his- 
tory, philosophy and the natural sciences. These schools should 
be in charge of intelligent instructors, who would give all their 
time to the patients, eating at the same table with them, joining in 
their walks and recreations, providing them with amusement, and 
undertaking no labor or duty except that of interesting those under 
their care and contributing to their happiness by conversation and 
companionship. They ought not to have anything to do with 
coercive measures, in order that patients may not be prejudiced 
against them and become ill at ease in their presence. They should 
encourage the timid, comfort the despondent and contribute to the 
cheerfulness and contentment of all. 

He believed that schools were especially useful in arousing 
patients and calling into exercise the faculties of the mind which 
were becoming dormant and inactive. He would have all such 
patients devote a portion of the day to study with a view to mental 
development. He also believed that the melancholy and despair- 
ing, as well as all who sufifered from delusions, or were restless 
and nervous largely from lack of occupation, were frequently 
cured by mental occupation, such as school exercises, writing com- 
positions, uttering declamations, acting in plays, etc. In his opinion 
a lack of mental occupation was the great fault in modern institu- 
tions for the insane. While walking, riding, etc., soon became 
mechanical, and therefore furnished but limited enjoyment, attend- 
ing school, he believed, provided mental occupation which, by 
requiring attention and effort, really interested the patient. He 
laid special stress upon the benefit to be obtained from a museum 
or a collection of minerals, shells, pictures, specimens of archi- 
tecture or of modern art, and curios of all kinds, as calculated to 
engage the attention and stimulate mental eiTorl. 

It is evident that Rrigham, in this respect, was far in advance 
of his time, and possibly of any time. 



NON-MEDICAL TREATMENT OF THE INSANE 237 

The most ardent supporter of the restraint system was probably 
the well-known Isaac Ray. His views may be found in the second 
volume of the Journal of Insanity, which contains an extract from 
a report presented by him upon the use of mechanical restraint, in 
which he argues that the interests of the insane do not require the 
disuse of all restraint and declares it must be proved either that 
restraints are positively injurious to the patient or that their 
intended object can better be obtained in some other way. Neither 
of these facts, he says, has been established to his satisfaction. 
He has no hesitation in saying that mechanical restraint is far pref- 
erable to the vigilance or force of attendants and is far less 
annoying to the patient. The mechanical contrivance, he says, 
" performs its office steadily, uniformly, thoroughly, and is sub- 
mitted to as something inevitable.'" The vigilance of attendants 
and the exercise of their wills are capricious and variable. 

There could be little doubt that his view in this respect is correct, 
if the only substitute for mechanical restraint in the management 
of an excited patient is to hold him constantly by the hands of an 
attendant. But Dr. Ray evidently fails to appreciate the usefulness 
of supplying some other means of employing his energies by walk- 
ing or labor, or some occupation requiring the exertion of muscular 
strength. He goes on at great length to speak of the irritating 
character of manual restraint and praises the use of a simple 
leather strap whereby the patient is gently held upon his bed, but is 
able to turn from side to side, and of the muff or mitten which 
enables the patient to control his own bodily movements with per- 
fect safety. 

He does not endorse the statement that the application of 
mechanical restraint is liable to abuse and often leaves disagree- 
able impressions on the mind of the patient, and he expresses the 
belief that if restraining apparatus is applied by order of the 
medical officer alone, as is the case in his institution, and is used no 
longer than it is absolutely necessary to control the patient, it minis- 
ters to his comfort. 

In discussing the extent to which restraint is in use, he states 
that the actual number of persons under restraint in his institution 
daily may at most amount to four or five, but that the average num- 
ber does not probably exceed two or three. It is evident from 
another portion of his argument that the question of economy 



238 INSTITUTIONAL CARE OF THE INSANE 

entered somewhat into consideration. To furnish sufficient nurses 
and attendants to care for patients without restraint would seem 
to him to require a large increase in the number of attendants. 
" And thus," he says, " the expense of the establishment would be 
swelled to a very onerous amount." 

In an elaborate and highly interesting article published some- 
what later, Ray describes the European institutions for the insane, 
enters very fully into the question of restraint and non-restraint 
and shows the beginning of the movement in favor of restraint 
which developed later in the United States. 

He regarded mechanical restraint not simply as a choice between 
restraint at the hands of attendants and restraint by means of an 
unyielding impersonal agency, but rather as a curative measure. 
In his opinion, the institutions of Great Britain were not as com- 
fortable as those of the United States and he states that in his visit 
he detected many evidences that non-restraint did not accomplish 
the good claimed for it by its advocates. He recognized with some 
surprise the greater quiet of the European institutions as compared 
with those of the United States and ascribes it to the fact that the 
inmates were from the pauper class, a class entirely unknown in 
the United States. " We have no poor," he says, " supported by 
public charity. What I mean is that our poverty is a casual condi- 
tion, a temporary misfortune, the result of accident, disease or 
mischance, and dies out with its unfortunate subject." He believed 
that the poor patient in the American asylums is by nature fresh 
and buoyant, with his energies in full vigor, and that consequently, 
when put into an institution he became restless, uneasy and anxious 
to be relieved of all personal restraint. While there may be some 
weight in Ray's argument, it is evident that he did not approach 
the subject with a wholly unbiased mind and was inclined to defend 
the use of restraint in America as more or less a matter of 
patriotism. 

It is evident, however, that, as the result of discussions appear- 
ing in many of the annual reports of superintendents of institutions 
for the insane, a feeling grew up that mechanical restraint was a 
curative agency, the use of which, though it might be abused, was 
preferable, in spite of its faults, to its entire abandonment. 

Another clement in the increased use of mechanical restraint 
was undoubtedly the fact that institutions grew and enlarged 



NON-MEDICAL TREATMENT OF THE INSANE 239 

beyond the orig^inal intention of those in charge of them. The 
superintendent's time and energies were claimed not only by 
his professional duties but by others of a non-professional char- 
acter, such as the care of the farm, the kitchen and the laundry, to 
say nothing of numberless outside affairs which devolved upon him 
because of his prominence in the state and his public-spirited 
citizenship. 

Under these circumstances, it is plain that the work of caring 
for the patients had to be more and more delegated to others and 
the pinching economy which characterized the management of the 
early institutions for the insane unfortunately kept the medical 
staff down to the lowest point. The physician-in-chief was the- 
oretically supposed to do everything and the number of his assist- 
ants was very limited ; often, indeed, he had but one, whose duties 
were as varied as those of his chief. As a result of this state of 
things, it became necessary to transfer more and more of the 
personal control of the patients to lay under-ofificers, such as 
matrons, supervisors, head attendants and the like, a condition of 
things which induced increasing latitude in the use of restraining 
apparatus. Patients were often violent or destructive, and as their 
condition was not then fully understood, and their destructive 
habits were the cause of serious expense to the institution, 
many superintendents considered it essential to employ restraining 
apparatus. 

We now know that this system tended to beget additional de- 
mand for restraint. Mechanical restraint being easily applied, and 
not requiring much personal exertion on the part of physician or 
nurse, came to be regarded as a panacea for many unpleasant 
features of insanity. Unfortunately, as has often been pointed out, 
the influence of the use of restraint upon the patient himself was 
not sufficiently considered. The statement was made again and 
again in the published writings of the early members of the Asso- 
ciation as well as in their discussions that lack of self-control was 
the most prominent feature in mental disease, and that when self- 
control was restored most of the unpleasant features of insanity 
disappeared. It was consequently very easy to jump to the con- 
clusion that if a violent patient was restrained his powers of self- 
control were in a certain way increased, but it was forgotten that 
self-control comes from within and not from outside methods. 



240 INSTITUTIONAL CARE OF THE INSANE 

Hence, in the majority of cases the patient who had an imperfect 
appreciation of his own condition misunderstood and misappre- 
hended the object of restraint. It was impossible, in the majority 
of instances, for him to regard it as anything else than a punish- 
ment and an interference, if not an indignity, which he felt he 
did not deserve. Unquestionably this conviction was frequently 
impressed upon his mind by those who had him in charge, who 
usually threatened that if he did not exercise self-control and 
refrain from acts of violence he would be placed in restraint. 
Whatever motive might originally have actuated the physicians in 
charge or the officer to whom the authority to apply restraint had 
been delegated, it is undoubtedly true that in the majority of 
instances patients and their attendants both regarded the applica- 
tion of mechanical restraint as a species of punishment or at least as 
a penalty for a lack of self-control. Consequently there grew up 
in the mind of the patient a feeling of resentment, and unquestion- 
ably habits of violence, destructiveness and morbid tendencies in 
various directions were rather cultivated than repressed by the 
application of mechanical restraint. Those who came into institu- 
tions a generation or two later found a large number of patients 
whose condition was deplorable. They were noisy, destructive to 
clothing and furniture, untidy in their habits, and incapable of 
employment, because of more or less constant seclusion and re- 
straint. The efifect of all this was to engraft upon the system of 
care which prevailed generally in early institutions a false method, 
which finally extended to nearly all the institutions of the country. 
Instead of restraint being regarded as a necessary evil, to be used 
only in the most serious emergency, it came to be looked upon as a 
necessity in the growth of institutions and the consequent increase 
not only in the number of patients, but in the number of unskilled 
and untried medical men entrusted with the care of them. Under 
these conditions the use of mechanical restraint was upheld and 
defended as a salutary measure essential to the successful and 
proper treatment of patients. 

The years i860 to 1880 marked the high-water mark of the ten- 
dency to employ mechanical restraint. The use of it was lauded 
by many superintendents as one of the most beneficent means of 
treating the insane, and the good condition of the institutions in the 
United States where restraint was practiced was contrasted with 



NON-MEDICAL TREATMENT OF THE INSANE 2^1 

the deplorable conditions in England where restraint was not per- 
mitted and could only be used in the most stringent emergencies. 
At length, however, it became apparent that the development of 
industries in institutions and the introduction of employment, 
amusements and open air life had a marked effect in quieting pa- 
tients and promoting their morale ; while under these influences 
the unpleasant forms of insanity, which had been supposed to 
require restraint, but had really developed under it and in many 
instances been created by it, were found to disappear. Patients 
who had been supposed to be more excited or violent or outrageous 
generally than English patients, because of the greater excitement 
of the climate of America, were discovered to be very much the 
same as insane patients in England, and it became plain that a 
change in the type of the insane had in reality been produced by 
faulty methods of care and treatment. 

We now know that the evils of non-restraint were exaggerated 
and the curative influences of mechanical restraint were unduly 
dwelt upon. There is little doubt in the minds of those who were 
familiar with institutions for the insane 40 years ago and who see 
them at the present time that the abolition of mechanical restraint 
and the substitution of prolonged baths, occupations, amusements, 
exercise in the open air and personal care have effected a great 
change in the type of mental disorder and that insane patients are 
in every way more comfortable than they were in former times, 
and above all that the relations between the nurse and the patient 
have vastly changed for the better. 



V. 
EMPLOYMENT FOR THE INSANE. 

It is evident from an examination of reports of earlier institu- 
tions for the insane that their medical officers had an excellent 
appreciation of the benefits of employment, recreation and proper 
amusement. 

The importance of schools was early recognized by those who 
were engaged in the organization of the first institutions for the 
insane. They were considered a form of so-called moral treatment 
and were beneficial as we know now, because they furnished a 
system of re-education. Among the earlier patients under treat- 
ment there were many who, owing to pioneer conditions, had few 
opportunities to acquire the simplest form of education. Conse- 
quently simple school exercises were great advantages to them 
when they were convalescent from mental trouble, usually an 
attack of excitement, because such was generally regarded the only 
form of insanity which required hospital treatment in early days. 
To such patients, regular, systematic instruction in the simplest 
rudiments of education, like reading, writing and arithmetic, was 
extremely beneficial, because it gave not only occupation but 
also healthful exercise for the mind in a way which did not overtax 
it. These exercises grew more difficult only when the patient's 
education and mental vigor had increased, so that there was little 
danger that he would become fatigued or exhausted by excessive 
mental labor. In the later schools for the insane the mistake was 
sometimes made of prescribing studies which were too difficult, and 
in some instances patients broke down while endeavoring to pursue 
them. One of the most interesting accounts of such schools for 
the insane is given in Volume i, page 326, of the American Journal 
of Insanity. This describes the routine pursued in the New York 
State Lunatic Asylum. The subject is continued in Volume 11, 
page 284. 

The Utica State Hospital and the Hartford Retreat were 
pioneers in the introduction of schools and employments as cura- 
tive agencies, and in the first number of the Journal of Insanity Dr. 
Brigham gives an account of the efforts then made to employ 



EMPLOYMENT FOR THE INSANE 243 

patients as follows : " Attached to the asylum at Utica is an excel- 
lent farm, where the patients in good weather perform much labor 
and also in the garden, by all of which they are much gratified and 
improved. Some work in the joiner's shops, some make and repair 
mattresses, and others work at making and mending shoes. The 
women make clothing, bedding and do the ironing and assist in 
various household duties. They also manufacture many useful 
fancy articles for sale." He goes on to describe a fair that had 
been held a month before for the sale of articles manufactured by 
patients at the asylum and quotes from a daily newspaper a pas- 
sage showing how every one was surprised at the beauty of the 
fabrics and the skill and ingenuity displayed in their manufacture. 
There were dolls of every dimension, baskets, caps, stockings, 
gloves, aprons, collars, bags, purses, etc., in abundance. 

Schools for both sexes had been established from which good 
results had been obtained. The winter session of the school had 
been closed by an exhibition at which there had been given original 
pieces, recitations, music and original plays which would not have 
been discreditable to any literary institution. 

In giving an account of the daily routine of the asylum, after 
mentioning the hours of rising, of meals and of house work, he 
speaks of those patients who are permitted to labor on the farm, in 
the garden, about the halls and yards or in the shops, and says 
that many more usually volunteer to engage in work than it is 
deemed prudent to employ. " Those who do not labor," he says, 
" pass their time reading, playing ball, rolling nine pins, in walking 
or attending school. The women work much of the time ; they 
also take drives, walk, play battledore and attend school." 

In a following number of the Journal of Insanity he gives a 
description of the school at the Utica State Hospital. " There are," 
he says, " three schools for men, one managed wholly by a patient, 
the other two by a teacher hired for the purpose, and one school for 
women conducted by a hired teacher. School sessions commence 
at 10 in the morning and at 3 in the afternoon and each session con- 
tinues for one hour. They were opened and closed by the singing 
of a hymn. The patients read, spell, answer questions in arith- 
metic, geography and history and are assisted by blackboards and 
a globe. The majority commit pieces to memory and once in two 
weeks there is a meeting of all the schools in the chapel, when they 



244 INSTITUTIONAL CARE OF THE INSANE 

unite in singing, which is followed by declamations, reading and 
compositions. Some patients have learned to read and write at 
these schools. Several who were depressed have been much im- 
proved by attending school and a considerable number who were 
approaching a demented state have been improved in mind and 
have become interested in learning." 

In a later article an account is given of the establishment at the 
Utica State Hospital of what are termed " whittling schools," in 
which, " in addition to carved reproductions of all ordinary objects, 
such as houses, temples, ships, chains, etc., as well as all four- 
footed and two-legged and creeping things, there were many works 
of pure imagination presenting strongly marked characteristics of 
the asylum school/' 

The theory held by Dr. Brigham and also by Dr. Todd, of Hart- 
ford, was that employment, to be of benefit to the patient, should 
not consider the question of gainful occupation. In their opinions 
it should be of a character to divert the patient from his morbid 
fancies, to engage his attention, stimulate his interest, and lead him 
to resume natural and healthy methods of thought and of occupa- 
tion. Hence Dr. Brigham advocated the establishment of the 
" whittling shop," mentioned above, and also made plans for a 
printing office and other smaller industries in connection with his 
institution. He spoke repeatedly of the advantage of household 
occupations, such as gardening and flower raising for women, with 
out-of-door labor, upon the farm and garden or about the building, 
for men. 

It will be observed that these schools were a part of the hospital 
routine. As long as Dr. Brigham continued superintendent, and 
during the superintendency of Dr. Benedict, his successor, they 
continued in operation. Under the superintendency of Dr. John P. 
Gray they were discontinued, and in a discussion in the Association 
in after years he assigned as a reason for their discontinuance that 
they had proved too monotonous ; and declared that other forms of 
amusement and occupation were better suited to convalescent 
patients. Dr. Gray probably generalized too widely from insuf- 
ficient data. One of his assistants. Dr. J. B. Andrews, when he 
opened the BufTalo State Hospital later organized a school which 
has been in regular operation ever since and has proven of great 
service to patients, especially to those who had received an imper- 



EMPLOYMENT FOR THE INSANE 245 

feet education or who had been born in a foreign country and 
desired to acquire a knowledge of English. We have no means of 
knowing how generally schools were employed at first for the edu- 
cation and diversion of patients, but they seem at one time to have 
been quite common. 

At the New York State Lunatic Asylum, in addition to the regu- 
lar studies of the school, a schedule was adopted by which on two 
evenings of the week the patients listened to reading ; on two other 
evenings there was card playing, and on the fifth evening dancing, 
in which the patients participated. There was also a weekly lecture 
in the afternoon and entertainments in the amusement hall, such as 
concerts, theatricals and social events. 

In the matter of out-door employment there were games of ball, 
quoits and battledore. The women engaged in drawing, painting, 
dancing, music and sewing. The men were employed in farm 
labor. The school hours were from lo to 1 1 a. m., and from 3 to 4 
p. m. 

In a recent personal communication Dr. Mary Lawson Nefif, 
who had long directed occupations and amusements in the institu- 
tions of Massachusetts, reports that out of 60 institutions which 
she had visited, only one retains its school. 

On the other hand Dr. Eyman, of Massillon State Hospital, 
Ohio, gives the following interesting details respecting his school : 

During the past year a school has been in session at this hospital. 
Through a private donation a sum of money was obtained sufficient to pur- 
chase the material, and, under the direction of the superintendent, the work 
of construction was practically done by the patients. The building is brick, 
two stories in height, with a basement ; the dimensions are 45 by 86. It is 
in a sightly portion of the estate, on the edge of a hill, and below it is an 
open field for tennis courts and baseball. At each end is a wide porch and 
a wing, with stairways leading to the basement. The basement accommo- 
dates billiard tables and a bowling alley. The first floor contains two 
rooms separated by a single hall ; one is the library and reading room and 
the other is a class room. The second floor contains a single large hall 
which is used as a gymnasium. The room is supplied with electric lights 
and is heated by steam. 

Two teachers are provided for the school and about 100 patients per 
day are in attendance. Three sessions are held daily, two for women and 
one for men. The subjects are oral arithmetic, reading and spelling. The 
patients, in addition, are encouraged to relate stories and incidents from 
their experience bearing on whatever subject is under discussion. There 
are also spelling contests and special recitations and songs. Free-hand 



246 INSTITUTIONAL CARE OF THE INSANE 

drawing and tlie study of German have also been introduced, and special 
classes in history and geography have been formed. 

Each session begins with opening exercises, consisting of songs and piano 
music, followed by a talk on some subject of special interest, or the teacher 
may read to all an interesting story. There is a general feeling of willing- 
ness to engage in school work, but very naturally the conditions are some- 
what like those of an ungraded school ; many patients who are unable to 
take any active part are contented to listen and seem to enjoy the com- 
panionship and work of others. Others also are timid and require special 
effort to put them at their ease until they are able to take a part with the 
others. It has been the aim of the superintendent of the hospital to make 
an appeal to the patients to recall and reproduce as vividly as possible their 
former school days, and to awaken and stimulate early associations, with 
the hope that the stream of thought may thus be brought back to a natural 
channel. For this reason the school is an old-fashioned school and the 
text-books used are of the old type. An effort is made to vary the 
instruction and to give a sustained interest to the exercises. The questions 
and subjects are simple in character and the patients are encouraged to 
speak of the experiences and ideas which the lessons suggest to them. The 
last 20 or 30 minutes of each session are given to calisthenics in the 
gymnasium, beginning with a simple march to music and followed by a 
simple gymnastic drill, with definite commands and without apparatus. At 
the close of the drill the patients join in old-fashioned games, like drop the 
handkerchief, London Bridge and fox and geese. 

In addition to the special work of instruction, patients are permitted to 
come to the library to play games, to read the newspapers and magazines 
and to write letters. There is also a piano in the school room and the 
music for the exercises is furnished by patients. 

In the matter of occupation it is interesting to notice that many 
institutions now have separate buildings for occupations and recre- 
ations. There are occupation rooms at Warren, Pa. ; at North- 
ampton, Mass. ; at the Friends' Hospital at Frankford ; at the Shep- 
pard and Enoch Pratt Hospital, Maryland ; at Plarrisburg, Pa., and 
in many other similar institutions. In Northampton, Mass., it is 
interesting to recall that under the superintendency of Dr. Pliny 
Earle some form of amusement was presented to the patients every 
evening in the week, attendance upon which was voluntary. There 
was, however, a moral compulsion on the part of the patients to go, 
because they appreciated the fact that it was much better to sit 
in a well-lighted, well-filled amusement hall with good company 
than to remain in a lonely ward with comparatively few associates. 

In the matter of employment, it is interesting to notice an early 
report from Dr. Stribling, of the Western Lunatic Asylum, at 



EMPLOYMENT FOR THE INSANE 247 

Staunton, Va., in which he urges that the directors purchase slaves 
as necessary to the successful operation of the asylum, " because," 
he says, " the services of slaves cannot be dispensed with." This 
would seem to indicate that little was attempted in the way of labor 
on the part of the patients. 

In the report of the South Carolina State Hospital, on the other 
hand, some excellent observations occur on methods of employ- 
ment to influence the brain to resume its healthy functions and to 
return to its normal state. Dr. Trevezant, the superintendent, says : 
" But how is the attention to be fixed and the mind employed and 
morbid ideas replaced but by pleasant conversation, exercise, 
steady and sustained employment?" He goes on to mention the 
custom prevailing in Northern institutions of keeping the patients 
employed at some trade on the farms and thus giving them full 
exercise and something to occupy their minds so that they are com- 
pelled to think, their feelings and their thoughts are diverted from 
the sources of misery and distraction which had shattered their 
intellectual powers, and asks, " But what course is to be adopted 
with those who will neither work nor engage in amusements ?" To 
this question he replies : " I have no hesitation in saying that they 
should be forced" ; and cites as example the discipline used for the 
sick and the exertions which children are compelled to make to 
their own advantage. Dr. Trevezant also seems to appreciate the 
fact that many patients who cannot be induced to work and have 
been permitted to lounge about have become imbeciles and lost the 
little intellect they possessed. He inquires whether means can be 
devised to compel them to take exercise without using punishment 
or violence or coercion. He believes that such means can be 
devised and urges the Board of Regents of the hospital to furnish 
him with proper recreation for the patients and to supply them with 
proper work and expresses the hope that "you will not permit your 
feelings to get the better of your judgment and prevent the estab- 
lishment of such means as will furnish involuntary and compulsive 
labor to those who would otherwise be idle, and that it be continued 
until the beneficial eflfects are no longer necessary." 

Dr. Trevezant seems to have been a physician far in advance of 
his time, but it is doubtful whether the regents of the hospital did 
give him the means which he desired for recreation and proper 
work. 



248 INSTITUTIONAL CARE OF THE INSANE 

During the " restraint " period which later developed in Ameri- 
can institutions the systematic employment of patients was carried 
on fitfully and unsatisfactorily. Many states possessed but a single 
state institution for the treatment of acute cases. As soon as a 
patient had attained some degree of health, or if a chronic case had 
acquired sufficient self-control to leave the institution, it was cus- 
tomary to return him to his friends, or to the county almshouse or 
asylum in order to give place to a patient in an acute stage of 
his disease. This comparatively rapid movement of hospital popu- 
lation deprived the state institution of the opportunity to develop 
any fixed or settled employment for patients as a class. 

Later on, labor in household duties in the wards, in the gardens 
and about the grounds was attempted and in many instances suc- 
cessfully accomplished, but such labor fell almost wholly upon 
chronic cases who for various reasons had been retained in the 
institution. With the development of non-restraint methods it 
became essential to supplement household duties by occupations 
and industries calculated to interest and engross the attention of 
all classes of patients, acute as well as chronic. 

Among the earlier industries which unquestionably proved of 
great service to patients during the stage of convalescence the first 
place should be given to ordinary farm labor, such as feeding 
cattle, milking cows, and other agricultural operations which the 
majority of patients from the rural districts pursued at home. In 
institutions established in the newer sections of the country large 
numbers of patients have been employed in clearing and grading 
grounds and in the wheel-barrow work necessitated by excavations 
and new roads. In a few institutions brick-making was developed 
as an industry, patients being engaged in excavating the clay, tem- 
pering and mixing it and afterwards moulding it into bricks which 
were subsequently burned and used in the construction of addi- 
tional buildings. This was done in Virginia, Idaho and other 
states. In Long Island, at Central Islip, a large number of patients 
were employed in clearing land, removing trees and brush and in 
making roads. It is an interesting fact that many patients who 
have been thus usefully and profitably employed, both for them- 
selves and for the institution, had not been accustomed to out- 
of-door labor in any form prior to leaving home. They were city- 
born and bred and many had been tailors, artisans, mechanics and 



EMPLOYMENT FOR THE INSANE 249 

frequently piece workers, whose work had been wholly done by 
hand in the shop or at home. It was found that no class of 
patients showed more interest and enthusiasm in out-of-door work 
or received greater benefit from it. 

During the period from 1870 to 1890 there was a large develop- 
ment of indoor industries in connection with the various state insti- 
tutions. These took the form of manufacturing boots and shoes, 
clothing, brushes, carpets, mattresses and furniture, as w^ell as type 
setting, all of these being in-door trades. The development of out- 
of-door occupations has been regarded as upon the whole more 
satisfactory, because they generally bring an ample return to the 
institution. If the large amount of labor available in institutions 
for the insane were applied to a systemized industry it would 
unquestionably produce large results from a manufacturing stand- 
point, if that alone is worthy to be considered, but there are serious 
difficulties in finding a market for the product. It might, in fact, 
require legislative action to compel all state institutions to purchase 
articles thus manufactured, as is the case in Xew York in connec- 
tion with prison industries. Those most familiar with industries 
among the insane are doubtful as to the development of industries 
in. institutions beyond those required to supply the necessities of 
the institutions themselves. 

Experience has shown that industries which contribute directly 
to the patient's improvement in health, strength and mental vigor 
have a direct curative influence and that occupations from this 
standpoint can be advocated and should be maintained as a direct 
curative measure. Where, however, the question of gainful occu- 
pation enters in, there is reason to fear that the well-being and cure 
of the patient may not ahvays be properly regarded ; hence the 
majority of superintendents believe that it is preferable to employ 
patients in the open air, in such labor as directly lessens the expense 
of the individual institution rather than in any form of cornxmercial- 
ized industry. 

All agree that forms of occupation should be suited to the 
strength and capacity of the patient, and that they should be 
employed under the direction of a physician. 

In some states a law exists whereby authority is given to medical 
officers of institutions to give employment to patients solely as a 
mode of treatment. This has apparently worked well. 
23 



VI. 

ASYLUM PERIODICALS. 

The first asylum periodical was issued under the following 
circumstances: In 1837 one of the patients of the Hartford 
Retreat, who had been a printer, and also an editor, repaired to 
one of the printing ofifices in Hartford, and with the assistance 
there obtained, issued two numbers only, of a little sheet called 
the Retreat Gazette. He remained under treatment for some 
time, and was discharged without being restored. 

" The Asylum Journal was the first regular newspaper ever 
printed in and issued from a lunatic asylum." It was published 
and printed at the Vermont Asylum for the Insane, located at 
Brattleboro. Its first number bears date November i, 1842. It 
was originated by a young man seventeen years of age, a printer 
by trade, who was admitted to the asylum, July 15, 1842, and 
the general management of it was almost wholly in his hands 
during the first two years. Other inmates, however, contrib- 
uted to its columns ; it was a weekly, single sheet, ten by twelve 
inches in size. The terms were one dollar per annum, and the 
profits were to be applied to the support of the indigent insane at 
the asylum. It bore the appropriate motto, " Semel insanivimus 
omnes." " We have all, at some time, been mad." It claimed as its 
object the dissemination of correct views of the condition and 
proper treatment of the insane. On the first of January, 1843, the 
price was reduced to fifty cents per annum, and was so continued 
for two years. At that time, as several who were engaged in its 
printing were " considered by the majority of mankind to be 
sane " and left the asylum, the Journal was issued only monthly, 
and the price was reduced to tw^enty-five cents per annum. After 
two years, covering a total existence of four years, it was sus- 
pended. Of the pecuniary aid toward supporting the indigent 
insane, we cannot speak, but a substantial benefit to the patients 
and the institution was derived from its list of exchanges, which 
exceeded two hundred in number. In his report for the year 1847, 
Dr. Rockwell observes : " The printing of the Asylum Journal has 
been discontinued in consequence of the recovery of the printers, 
who have left the asylum." 



ASYLUM PERIODICALS 25I 

The next asylum periodical in this country was the Opal. This 
was printed and published at the State Asylum at Utica, N. Y. It 
was begun on the ist of January, 185 1, issued monthly, in news- 
paper form, a double sheet, ten by twelve inches, and furnished at 
fifty cents per annum. Its motto was " Devoted to Usefulness," 
and its object to increase the library of the institution by the profits, 
if any accrued, and to extend a knowledge of " our " wants to a 
generous public who can but be interested in " our " welfare. From 
the report of the institution for 185 1, we learn that during the first 
year of its publication it had " an exchange list of two hundred and 
twenty weeklies, four semi-weeklies, eight dailies and thirty-three 
monthlies, and that the number was still on the increase." It was 
continued in magazine form, double its former size and subscrip- 
tion price. In 1852 its exchange list was increased to over three 
hundred newspapers and periodicals, and the subscription fund 
furnished an addition of several hundred volumes to the library. 
In 1854 it is reported that the proceeds from the Opal and from the 
ladies' fair amounted to four hundred dollars, which were expended 
in books, improvements to the green house and in amusements. In 
1855 the amount derived from the same sources was six hundred 
dollars, which were used to purchase an oil portrait of Dr. A. Brig- 
ham, the former superintendent, and a piano. The report for 1857 
contains the last reference to the Opal: " From our printing office 
are regularly issued the Opal and the American Journal of Insan- 
ity. The former, a monthly of twenty-four pages, now at the close 
of its seventh volume, is entirely original, and the production of the 
patients The large number of newspapers and mag- 
azines received in exchange furnish abundant reading matter for 
the entire household. The programmes for our entertainments and 
concerts, blanks, book labels, etc., are printed in the institution. In 
the building attached to the printing office, all of our exchanges 
and pamphlets are bound, and the successive issues of the Journal 
and Opal are stitched and prepared for mailing." In appearance, 
the Opal compared favorably with the various subscription maga- 
zines. The first page of the cover was ornamented with an engrav- 
ing of the illustrious Pinel ; the paper was good, the type clear, and 
the character of the articles interesting. It closed its career with 
the third number of the tenth volume. We quote from the vale- 
dictory : " We believe the world is wiser, if not better, for our Opal. 



252 INSTITUTIONAL CARE OF THE INSANE 

It has cleared up so many doubts, dissipated so many errors and 
wrong opinions concerning monomania and insanity. It has taught 
outsiders how Httle difference in ideas there often is between those 
within and those without the walls. It has shown how very diffi- 
cult it is to tell where melancholy ends and insanity begins : how 
narrow the boundary between eccentricity and lunacy, and it might 
tell how much better insane people behave under the asylum code 
of etiquette than the world's votaries often do. 

" It should have taught them that not a multiplicity of cares or 
anxieties is the chief agent in bringing about such mournful results, 
but the same enemy to peace, 

' Which crazed King Lear, 
The continual racking of brain with one idea.' " 

The success of the Opal during the first few years of its exist- 
ence was marked and gratifying. A large edition was printed, and 
most of it was advantageously disposed of. This flourishing state 
was, however, of comparatively short duration. After a few years 
the novelty to the public wore off, subscriptions declined, and 
exchanges were discontinued. During the last three years an 
examination of the books, which were kept by an assistant phy- 
sician of the asylum staff, showed that the receipts amounted to less 
than the expenditures. 

Other causes were also operative ; some of its best contributors 
recovered and were discharged ; the editor, the printer and the 
binder, declined in mental power, from the progress of disease, and 
soon after died. The breaking out of the war in the Spring of 1861 
turned the minds of all the household in that direction, and they 
became much interested in laboring for the cause of the sol- 
diers. This took the place largely of the work formerly done upon 
the Opal, and of the fairs. The report of that year shows that 
the female patients and attendants employed their leisure time in 
sewing, knitting, or making lint for the soldiers, and that the men 
contributed $306.50 in money, which was largely expended for the 
material worked up by the ladies. 

A long interval elapses before another newspaper venture was 
made in an American asylum. 

The first number of the Meteor was issued in July, 1872, from 
the Alabama Insane Hospital. This was a quarterly, single sheet 



ASYLUM PERIODICALS 253 

paper, nine by eleven inches. It bore the motto " Lucus a non 
Lucendo." It was edited by a patient, and printed at the hospital by 
patients. Original communications only were received. Its edition 
of several hundred copies was distributed to papers and patrons of 
the hospital. " We have hauled down our subscription rates, and 
will in future receive no subscriptions for the paper " was also 
announced. The object of the paper " is to keep the press, the 
people of Alabama, especially the patrons of the hospital, en 
rapport with the doings of the institution, and well abreast with 
the most advanced views in the care and treatment of the insane." 
In the accomplishment of this purpose its columns were largely 
filled with news of events transpiring in the hospital, and items 
from other institutions collected from exchanges. 

The Friend was the title of a paper of the same size as the 
Meteor, issued from the Pennsylvania State Hospital, at Harris- 
burg, and "conducted by an association of ladies." It com- 
menced its existence as a monthly in September, 1872, and was 
published regularly till April, 1874. The subscription price was 
fifty cents per annum. It was a sprightly little sheet largely made 
up of short witticisms, many of them excerpts. Its brief existence 
and its early death leave us little to say, and this should be only 
good. 

Many other ephemeral periodicals have appeared in connection 
with institutions which possessed the proper outfit for printing 
them, but the history of the journals sketched above by the late 
Dr. J. B. Andrews clearly points out the fate of these ventures. 
They prospered for a time owing to the industry and initiative 
of some one person who felt responsible for them and ceased to 
exist when by recovery or otherwise the individual passed from 
the institution. 



VII. 
INDIVIDUAL TREATMENT. 

The abolition of restraint brought permanently to the attention 
of superintendents of institutions the necessity of treating each 
patient as an individual ; it seems also to have become equally 
evident to nurses and employees that patients of every class require 
similar treatment if their condition is to be made comfortable. 

The attitude of nurses towards patients was in fact greatly 
changed by the abolition of restraint. Every nurse soon perceived 
that the best method of dealing with a violent, destructive and 
possibly dangerous patient was to be on friendly terms with him 
and to make him comfortable. It became necessary also to under- 
stand his thoughts and feelings ; to inquire why he was restless, 
apprehensive, or destructive; and, if he was violent, to determine 
how his excitement could be diverted from habitual violence or 
destructiveness into more healthful channels. 

Women nurses soon endeavored to interest their patients in 
the decoration of wards, in household work, fancy work, knitting, 
sewing, braiding rugs, making toilet articles, assisting in laundry 
work, darning stockings, mending clothing and other familiar 
occupations of home-life. In some hospitals old-fashioned spin- 
ning wheels were purchased for the employment of elderly women 
in spinning carded wool. Looms were also established, and in 
certain institutions at the South cotton was spun, woven into 
cloth and afterwards made into garments. 

Men nurses were equally zealous in studying the peculiarities of 
patients and in learning what employments and occupations were 
congenial. For a time there was a natural fear lest acts of violence 
might occur should patients be allowed free use of the facilities 
afiforded and the implements rc(juired by their different occupa- 
tions, but it soon became plain that dangerous tools could be 
placed in the hands of an insane patient with safety, as long as 
his energies were directed towards useful labor in which he felt 
an interest. Such individual study of each patient by nurse and 
physician had the advantage of securing a return of interest in 
definite forms of work, bv which healthful trains of thought were 



INDIVIDUAL TREATMENT 255 

suggested, to the exclusion of morbid fancies leading to violent 
conduct. Such individual study and treatment of patients have 
been of much benefit to the insane. In many institutions nurses 
were required to make careful records of the hallucinations, delu- 
sions and strange actions of their patients, a practice which taught 
them to observe their charges more carefully and to appreciate 
that insane conduct always has behind it an insane motive and is 
not caused by depravity or a desire to outrage the feelings of 
others. 



VIII. 
EXPERIMENTAL REMOVALS. 

It was found in some instances that patients developed delusions 
and strange fancies in connection with institutions where they 
resided, which consequently became unsuited to their curative 
treatment. This fact suggested to many superintendents the desir- 
ability of changing the patient's surroundings, or even of bringing 
him to his former place of residence, in order that he might com- 
pare his condition with that of his old friends and neighbors and 
thus ascertain whether or not he could adapt his ideas and conduct 
to his former condition of life and share in the activities and modes 
of thought which prevailed in his own communit}-. This gave 
rise to furloughs or experimental removals from hospitals for the 
insane. In some instances such experimental removals were not 
followed by beneficial results and a return to the institution became 
necessary. It was frequently observed, however, that the patient 
came back in a more normal condition than when he went away ; 
he appreciated the hospital better and understood his relations to 
the public as he had not before. Moreover, though he failed to 
adjust himself to his home during the first experimental removal, 
his experience often paved the way for a second trial, in which he- 
went home to remain permanently. 

In other similar instances a patient who returned home as 
an experiment was able to remain there, because during his stay 
in the hospital he had regained sufficient self-control to appreciate 
conditions which were not operative when he left his home. He 
perceived that unless he exercised self-restraint and did not allow 
his delusions to overcome him he would be returned to the institu- 
tion. His desire to remain away from the hospital gave him an 
incentive strong enough to enable him to control destructive tend- 
encies and to engage in industries which engrossed his attention 
and gave him a feeling that he had resumed his old place in the 
world. 

In most states experimental removals have been conducted 
informally, selected patients being allowed to go to the care of 
interested and devoted friends, who become responsible for their 



EXPERIMENTAL REMOVALS 257 

safekeeping with the understanding that they can return within 
six months or possibly one year without a fresh commitment should 
such return become advisable. The longer experimental removal 
is undoubtedly better than the shorter furlough. In some states 
a furlough of 30 days is allowed ; in others one of 50 days ; in still 
others one of 90 days ; in several one of six months ; and in a few 
states one of a year. It is probable that the majority of chronic 
patients who go away upon a furlough remain away permanently 
if the conditions of home life are satisfactory. In many instances, 
however, poverty, old age and the death of friends and natural 
protectors all conspire to bring about the return of a patient who 
might, under more favorable conditions, remain permanently at 
home. 



IX. 

ORIGIN OF THE PSYCHOPATHIC HOSPITAL IN THE 
UNITED STATES. 

For many years, in fact until 20 years ago, the main idea which 
governed the erection, organization and management of hospitals 
for the insane seemed to have been to provide for the custodial care 
of patients. It is true that the thought of treatment and cure 
already occupied the minds of many medical officers and was assid- 
uously dwelt upon in the reports of the dififerent hospitals. Unfor- 
tunately in the minds of the majority the idea of cure became a 
relief of violent symptoms and was closely associated with the 
theory that it was to be accomplished largely by the use of me- 
chanical restraint. For this reason it is not strange that in many 
institutions the custodial features of the work assumed undue 
importance, and the medical treatment of insanity was neglected. 

Between 1880 and 1890, however, many medical men went 
abroad and learned from practical observation the beneficial results 
of non-restraint. When they returned to their own institutions 
they saw the importance of dividing the two classes of the insane, 
the feeble, depressed and exhausted class from the robust, stout 
and active. Accordingly hospital wards, so-called, were set apart 
for the special care of the aged and feeble and those suffering from 
the more acute forms of mental disease. The remainder were for 
the most part cared for in old-fashioned wards, built on the Kirk- 
bride plan, but such patients as were capable of active labor upon 
the farm were housed in cottages or other detached buildings, 
where it was possible for them to enjoy greater freedom and to 
lead a life approximating that of home. 

Dr. W. B. Goldsmith, at the Danvers State Hospital, was one of 
the first to establish such hospital wards for the careful special 
treatment of acute cases, as in a general hospital. Similar wards 
were also constructed in Buffalo, Kankakee, Kalamazoo and 
Pontiac, Mich. Later they were used as reception wards for all 
patients admitted to the hospital. 

In BufTalo in 1895 the reception ward grew into a new depart- 
ment known as the Elmwood Building, which has since been used 
largely for the treatment of acute cases of both sexes. 



ORIGIN OF THE rSYCIIOPATIIIC HOSPITAL 259 

Following this, largely through the result of studies in Ger- 
many and especially through the writings and addresses of Dr. 
Peterson, subsequently Commissioner of Lunacy in New York, 
the desirability of the erection of psychopathic hospitals arranged 
for the treatment of mental diseases similarly to that of acute 
diseases in a general hospital began to bear fruit. Peterson's first 
publication, in fact, recommended the utilization of wards or de- 
partments of general hospitals so that mental disease might be 
treated by the same staff and under the direction of competent men, 
skilled in internal medicine. 

About the same time Dr. L. Pierce Clark, of Xew York, who 
had become interested in the study of epilepsy, published an elab- 
orate and instructive paper in the American Journal of Insanity on 
psychopathic wards in general hospitals and special psychopathic 
hospitals, which had much influence throughout the country. Dr. 
J. T. Eskridge of Denver also, in an address referred to in the 
" History of the Association," outlined his plans for the proper 
organization of a psychopathic hospital which called for internes 
and medical attendants of the same grade as in the best general 
hospitals, and a staff so numerous that each 50 patients should have 
one or more medical attendants. 

One of the first pavilions or wards established for the treat- 
ment of mental cases in a general hospital was established in con- 
nection with the new General Hospital at Albany, N. Y. It was 
known as Pavilion F and was situated in close proximity to the 
main hospital building, but in such a location that the excited 
patients might disturb the rest of the hospital as little as possible. 
This ward was placed under the special charge of Dr. J. Mont- 
gomery Mosher, a skilled and experienced alienist, who has borne 
the burden of it during the past 14 years and by his skill, energy 
and thorough work has shown the feasibility and utility of a 
mental ward in connection Avith a general hospital. 

About the same time, through the efforts of the late Dr. W. J. 
Herdman, of the University of Michigan, and with little or no 
co-operation on the part of other state hospitals, largely owing to 
the fact that the movement was initiated by persons who were 
not friendly to the state hospital system, the legislature of Mich- 
igan made an appropriation of $50,000 to establish a state psy- 
chopathic hospital in connection with the hospital of the Univer- 



26o INSTITUTIONAL CARE OF THE INSANE 

sity of Michigan. This hospital, owing to a variety of causes, 
was slow in becoming organized and did not attain complete suc- 
cess until it was placed under the charge of a board composed of 
the regents of the university and representatives from the different 
hospitals for the insane in Michigan. Since that time, under the 
admirable direction of Dr. Barrett, it has done excellent work 
in the care of recent cases and in the study and investigation of 
mental disease. 

The State Psychopathic Hospital of Massachusetts was next in 
order of establishment, under the auspices of the State Ijoard of 
Lunacy, as a department of the Boston State Hospital. Although 
nominally connected with the latter in its business management, 
it is practically independent. Its professional work is in charge 
of Dr. E. E. Southard, formerly pathologist of the Massachusetts 
state institutions. It enjoys an active service and receives nearly 
all committed cases from Boston and its vicinity. The medical 
stafif is large ; and valuable studies and research work in psy- 
chiatry are being prosecuted with great skill and success. 

About the same time hospital wards were erected in the McLean 
Hospital, Waverly ; Butler Hospital, at Providence ; and Blooming- 
dale Hospital, at White Plains. These hospitals were provided 
with quiet, secluded wards, special rooms, facilities for hydro- 
therapy and mechano-therapy and all the essentials of a general 
hospital for the treatment of acute diseases. 

There was also in connection with the lunacy service in the 
State of New York an extension of the State Pathological Insti- 
tute, then under the care of Dr. Adolf Meyer, through the co- 
operation of Dr. Mabon, the superintendent of the Manhattan 
State Hospital, whereby several wards were placed under the 
charge and medical care of men connected with the pathological 
institute. 

Later, through the liberality of Henry Phipps, of New York, 
the Henry Phipps Psychiatric Clinic, in connection with The Johns 
Hopkins Hospital, was built and endowed for a period of years for 
the care of hospital patients suflfering from mental disease. 

During the past three years legislation has been enacted in the 
State of Minnesota whereby each state hospital is rcciuired to 
establish a psychopathic hospital for the treatment of recent cases 
in that state. 



ORIGIN OF THE PSYCHOPATHIC HOSPITAL 261 

There is an evident confusion in the mind of the medical pro- 
fession as well as of the public as to the precise distinction between 
a detention hospital and a psychopathic hospital. In many in- 
stances the distinction is not made. In a few hospitals only the 
two functions seem combined. Thus, Pavilion F, of the Albany 
General Hospital, seems not so much a place of detention as of 
treatment, and, on the other hand, the psychopathic wards at 
Bellevue Hospital seem almost wholly places of observation and 
temporary detention, but not designed for treatment. The psy- 
chopathic wards at the Philadelphia Hospital are said to be de- 
signed both for detention and treatment. In reference to the 
Government Hospital at Washington, Dr. White writes : 

The reception wards at the Government Hospital for the Insane are, 
I think, properly speaking, psychopathic wards. The reception buildings 
for white male and white female patients are two large buildings of four 
wards, with a nominal capacity of 30 beds each. These buildings are well 
equipped ; they all contain up-to-date hydrotherapeutic installations and 
operation departments ; and we keep our best nurses there. The buildings 
are used largely for taking care of the acute sick who are sent there from 
the other portions of the hospital, particularly surgical cases. There is a 
reasonably well equipped reception ward for colored men and also for 
colored women, the latter having access to a hydrotherapeutic outfit. A 
similar equipment is now under consideration for colored men. 

Detention Hospitals. 

California seems to have been one of the first states to arrange 
what may be termed a system of detention hospitals for the insane 
who are awaiting admission to the state hospitals. In Los Angeles 
a large reception hospital has been erected and maintained by the 
county and city, although under the inspection and supervision of 
the Lunacy Commission and placed in charge of a physician 
experienced in mental practice. This hospital receives practically 
all insane persons who are taken up for examination, or are 
detained for treatment or who need to be under strict medical 
observation after discharge. It is located on the grounds of the 
hospital; has a court room in the building and inay be justly con- 
sidered a true psychopathic hospital. It is regarded as the best 
hospital provision for the insane in the state. 

San Francisco has a detention hospital which accommodates 
from 12 to 18 patients, but it is a place for detention rather than 
treatment of patients. An after-care physician attends all exami- 



262 INSTITUTIONAL CARE OF THE INSANE 

nations of alleged insane cases in court and the Lunacy Com- 
mission thus becomes cognizant of them and of changes in their 
condition. 

Oakland has a fair detention hospital in a separate building 
adjoining the Alameda County office building. Neither the San 
Francisco nor Oakland institution can be regarded as a psycho- 
pathic hospital. 

Dr. F. W. Hatch states that generally throughout California 
similar provision is made for the care of the insane who are await- 
ing commitment. In some counties two or more rooms are pro- 
vided in the county hospital and in others in the jail building, but 
apart from the jail proper, so tliat there may be no association 
with criminals. 

Outside of the Psychopathic Hospital at Los Angeles, insane 
cases are not usually detained more than 24 hours unless there 
may be great doubt as to the diagnosis of insanity. A woman 
nurse or attendant is provided for women in detention and accom- 
panies them if committed to a hospital. There has been much 
improvement throughout the state in the matter of detention hos- 
pitals, but much remains to be done, as there is often difficulty in 
inducing boards of county supervisors to provide sufficient attend- 
ants and nurses to protect and carefully observe all persons 
brought temporarily to these hospitals. It is also difficult fre- 
quently to secure from county sheriffs proper care of the rooms 
assigned to the insane, more especially those of male patients, 
as few male attendants are employed. The Lunacy Commission 
has no well-defined authority over these hospitals, but has the right 
to inspect and to make recommendations. 

In New York, by the provisions of a recent law, the care of 
insane persons prior to commitment to a state hospital is regarded 
as one of the proper functions of tlie health service of the state 
and made one of the duties of local health officers. In the boroughs 
of Manhattan and Bronx, however, the duty of properly caring 
for such persons devolves by law upon the Trustees of Rellevue 
and Allied Hospitals and in the other boroughs of New York 
and in the County of Albany upon the Commissioner of Public 
Charities. 

In no case may an insane person be confined in any other place 
than a state hospital or licensed private institution, nor be com- 



ORIGIN OF THE PSYCHOPATHIC HOSPITAL 263 

mitted as a disorderly person to a prison for criminals. Pending 
the transfer of an insane person to a public or private institution 
the proper ofificers must care for him in a suitable place and provide 
him with proper medical care and nursing. In Albany County 
such insane persons are sent to Pavilion F, of the Albany Hospital, 
the first psychopathic ward to be established in a general hospital. 
This ward has been in successful operation for the past 12 years 
and has cared for upwards of 3000 cases of incipient insanity 
during this period. A fuller description of it will be found among 
the histories of New York institutions. It is obvious that this 
method of care is of great service and should be imitated in many 
other municipal hospitals. 

In Minnesota detention hospitals have been established in con- 
nection with the state hospitals at St. Peter, Rochester and Fergus 
Falls, and all insane persons in Minnesota are committed to these 
institutions provisionally for a period not to exceed six weeks if 
it is found impracticable to determine the presence or absence of 
insanity sooner. 

In Massachusetts a person who suffers from insanity, mental 
confusion, except delirium tremens or drunkenness, cannot be 
placed in a jail or place of detention for criminals, but must be 
cared for by the Board of Health of the city or town in which he 
is found prior to commitment to an institution. He may be retained 
by the superintendent of a hospital for the insane without certifi- 
cate in an emergency for a period not to exceed seven days. 

In Michigan there are no detention hospitals, but a person 
believed to be insane may be detained for a period of not more 
than five days. 

In Pennsylvania a provision of law exists by which persons suf- 
fering from mental disorders may be committed for not more than 
30 days to the psychopathic wards of hospitals for observation and 
treatment, in the same manner as persons are committed to hos- 
pitals for the insane. If they are found to be insane they must be 
regularly committed and removed to a hospital for the insane 
within 30 days. 

In Philadelphia Dr. Woodbury writes : 

In the case of indigent patients who are taken up on the street by the 
police and who are suspected of mental disorder, the custom is to admit 
them to a psychopathic ward of the Philadelphia Hospital and detain them 



264 INSTITUTIONAL CARE OF THE INSANE 

there for a period long enough to determine the question of their sanity 
or insanity. If sane, they are discharged, but if they need medical treat- 
ment, they are transferred to another department of the hospital. If insane, 
they are examined by two physicians appointed for the purpose, who certify 
to the fact of their insanity and their need of care and treatment in an 
institution, and they are then transferred to the insane department of the 
Philadelphia Hospital, or sent to a state hospital. If they have a legal settle- 
ment outside of Philadelphia they are reported to the Committee on Lunacy 
and can be sent to their homes at the expense of the state. 

Indigent cases who are not committed by the police authorities 
may be received in the psychopathic ward in a similar manner on 
order from physicians appointed by the Health Department of the 
city. 

In cases of private patients their friends may take them imme- 
diately to a private hospital or a state hospital where a certain 
amount of discretion is given to the authorities in receiving them 
without papers. In cases of emergency an examination by phy- 
sicians may be made after the patient is already in an institution. 
Ordinarily, however, such examination and commitment under the 
Act of 1883, or by court, as the case may be, are made before 
taking the patient to the hospital. 

In Pennsylvania some years since so-called psychopathic wards 
were authorized in teaching hospitals and provision was made 
by law for payment by the state of a daily rate of $2 for each 
patient detained in them. The following account of the Psycho- 
pathic Department and State Observation Ward connected with 
St. Francis Hospital, Pittsburgh, will serve as an example of one 
of the newest of them : 

The present Psychopathic Hospital occupies a four story brick building, 
located in the rear of the General Hospital and connected with the General 
Hospital by three corridors. Its capacity is 229 beds. In the basement of 
the Psychopathic Hospital has been installed a well-equipped and modern 
hydrotherapy department, in charge of a graduate nurse, who has had 
special training in hydrotherapy, and of wide experience in hydrotherapeutic 
treatment of insane patients. Each floor is divided into an excited and 
quiet ward. Excited and chronic female patients are maintained on the 
fourth floor; the third floor is devoted to male patients; the second floor to 
female patients of acute and milder types of psychoses and female alcoholic 
patients ; the first floor contains the male alcoholic ward and the state obser- 
vation ward established in this hospital a year ago. The largest proportion 
of the work is with the psychoses of acute onset, and most of the cases are 
sooner or later transferred to a city, county or state institution. The 
average stay of a case in the hospital is about three months. 



ORIGIN OF THE PSYCHOPATHIC HOSPITAL 265 

Most of the cases are from among the working and middle 
classes of people. The Psychopathic Hospital in fact acts prac- 
tically as a clearing house for city, county and state institutions. 

The St. Francis State Observation Ward at Pittsburgh has a 
male and a female department, each of 12 beds capacity, and seems 
to be distinct from the Psychopathic Hospital. Only mental cases 
are accepted in this ward ; cases where doubt exists as to mental 
state and whether or not it is advisable to hold the patient under a 
regular commitment. Cases are kept against their will 30 days, at 
the end of which time they are regularly committed to the Psy- 
chopathic Hospital, or transferred to city, county or state institu- 
tion ; or, if recovered, they are discharged on parole. 

The practice in the District of Columbia is also somewhat simi- 
lar. Dr. White writes : 

Practically all insane persons apprehended in the District are taken to 
the Psychopathic Department of the Washington Asylum Hospital. This 
corresponds to the county hospital in other jurisdictions. Here they are 
kept indefinitely under the immediate supervision of the District alienist, 
and those patients who are suffering from acute conditions, such as delirium 
tremens, from which recovery takes place promptly, are not committed, but 
those who appear to have well-defined psychoses and which will require 
some time for treatment are then sent to the Government Hospital by the 
Commissioners of the District of Columbia under a temporary 30-days' 
commitment. During this period of 30 days they are cited into court and 
tried and committed. 

This practice has grown up without any special justification from a legal 
standpoint, but it has been the outgrowth of the efforts of two or three 
physicians to improve things in this jurisdiction. The psychopathic ward 
at the Washington Asylum Hospital, while it is overcrowded most of the 
time, and the equipment is very crude, does good work, and a short time 
ago received a sufficient amount of money to install in the basement a good 
hydrotherapeutic equipment. 

In South Carolina a person may be received upon certificates of 
insanity from two physicians without an order from the judge of 
probate for a period not to exceed five days. 

A similar provision of law exists also in Tennessee. 

In most of the remaining states the jail or the lock-up seems to 
constitute the only provision which is available for the emergency 
care of such emergency patients. 

The same also is reported to be true of the provinces in the 
Dominion of Canada. 

24 



X. 

THE STATE PSYCHOPATHIC HOSPITAL AT THE 
UNIVERSITY OF MICHIGAN/ 

The movement which led to the estabhshment of the State 
Psychopathic Hospital at the University of Michigan had its 
source in the increasing interest shown during the period between 
1890 and 1895 by institutions for the insane throughout this coun- 
try in the subject of pathological and scientific work. 

Michigan was fortunate in having a system of asylum adminis- 
tration which made it possible for these institutions to have 
mutual and effective discussions of matters relating -to hospital 
policies. This was established by the Legislature in 1877, when 
it was provided by statute that " it shall be the duty of the boards 
of trustees to meet jointly at least twice each year to adjust all 
questions which may arise pertaining to said institutions." This 
organization is known as the Joint Board of Trustees of the 
Hospitals of Alichigan. 

As early as 1887 we find a discussion in a paper by Dr. George 
C. Palmer, superintendent of the Michigan Asylum at Kalamazoo, 
of pathological and scientific work in the Michigan asylums. In 
this was expressed a dissatisfaction with existing conditions, and 
the proposal was made that the institutions should cooperate in 
their pathological work and have one pathologist, who should serve 
all of the state asylums. The recommendations of this paper were 
referred to a committee, which reported at the meeting a year later, 
in 1888. The committee recommended " that an assistant physician 
shall be appointed and designated to do microscopic and patholog- 
ical work for the three asylums of INTichigan in common, and that 
each one of these asylums shall defray one-third of his salary and 
expenses and shall have a right to his services." For some unex- 
plained reason these recommendations were laid upon the table and 
there was no further discussion regarding centralization of labora- 
tory work until ten years later, when, at a meeting of the joint 

* Furnished by Dr. Albert M. Barrett, director and pathologist of the 
Michigan state hospitals. 



PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN 267 

board, this subject was brought up for discussion in a paper by 
Dr. Wm. M. Edwards, superintendent of the asylum at Kalamazoo. 
In this a plan was proposed for establishing an affiliation of the 
state asylums for the insane with the University of Michigan in 
systematically conducted pathological work, which would be to the 
mutual advantage of both. This suggestion had already received 
the informal approval of the university. The recommendations 
were referred to a committee, consisting of the medical superin- 
tendents of the several asylums, to report at the next meeting. 

It is quite probable that the renewed interest of the Michigan 
asylums in this subject was stimulated by the consideration which 
had in recent years been given to centralization of pathological 
work by the New York Commission in Lunacy, which resulted in 
the organization of the Pathological Institute of the state hospitals 
in New York City in 1895. In this same period important advances 
in the development of clinical and laboratory work in hospitals for 
the insane had occurred at Kankakee, 111., in the changes in its 
work following the selection of Dr. Adolf Meyer as pathologist ; at 
McLean Hospital, in the organization of its new laboratories under 
Dr. August Hoch in 1895, and in the same year the reorganization 
of the laboratories at Danvers under Dr. William L. Worcester. 
Probably these events had an influence upon the committee then 
considering the recommendations for an affiliation with the univer- 
sity. As a result of conferences with a committee from the univer- 
sity, consisting of Dean Victor Vaughan and Regent Dr. Herman 
Keefer, the proposition was made at the meeting in November, 
1897, "that each Board of Trustees shall appropriate from its 
funds the sum of $125 for pathological work for a period of one 
year ; this sum to be paid as a salary to a competent pathologist to 
be recommended by the university authorities and approved by the 
Board of Trustees ; this pathologist to reside in Ann Arbor and to 
give his whole time to asylum pathological work under the direc- 
tion of the professor of pathology at the university." 

These recommendations were adopted, and the further arrange- 
ments were left to a committee composed of the medical superin- 
tendents. This committee, acting with one from the university, 
appointed Dr. Theophil Klingman, who was connected with the 
department of nervous diseases at the university, to serve as 
pathologist for the asylums of Michigan for one year beginning 



268 INSTITUTIONAL CARE OF THE INSANE 

January i, 1898. Each institution was to contribute ecjually towards 
his salary. 

The plan followed during the first year of this arrangement 
was largely experimental. No definite policy seems to have deter- 
mined the work. Visits were made by the pathologist to the vari- 
ous institutions and whatever laboratory work was undertaken 
was done at the university, with material sent from the asylums. 
At the next meeting of the Joint Board of Trustees in November, 
1898, the committee in charge of the pathological work was able 
to propose the following plan: " i. That each asylum or hospital 
pursue some work in general pathology. 2. That each asylum or 
hospital have one member of its stafif experienced in this line of 
work and given time for accomplishing scientific investigation in 
general and special pathology. 3. That the character of the work 
done be determined upon by the pathologist and members of the 
medical stafY of each institution. It was recommended that when 
practicable the instruction be given at the Michigan Asylum at 
Kalamazoo by the pathologist. 4. That an annual report be printed 
in addition to the biennial report, embodying the medical, surgical, 
clinical, pathological or psychological work." These recommenda- 
tions were adopted with the exception of that relating to the 
publication of a report. 

The relation of the asylums to the university was made still 
more intimate in 1898 by the appointment of the superintendents 
of the state asylums as special lecturers in the department of 
medicine of the university. For many years it had been the 
custom for medical students at the university to obtain much 
of their instruction in mental diseases from visits to one of the 
state asylums. Dr. Wm. J. Herdman, for many years professor 
of mental and nervous diseases at the university, was in charge of 
these visits. 

The plan which had been adopted did not seem to be completely 
satisfactory to the several asylums ; yet at the time any better 
arrangements did not seem possible. In a paper by Dr. E. A. 
Christian, presented to the Joint Board in 1900, it was mentioned 
" that the plan in Michigan may be conceded to be original and 
unique ; it may accomplish results at a minimum of cost without 
detracting from authoritative standing." It was decided to con- 
tinue the existing arrangement for another year. At this phase of 



PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN 269 

the situation in Michigan the idea of a special psychiatric hospital, 
with laboratories in which might be centralized the pathological 
work of the state asylums, began to assume shape. Quite inde- 
pendently of the movement for centralized laboratory work car- 
ried on by the asylums. Dr. Wm. J. Herdman developed a plan for 
the organization of a special division of the University Hospital 
which should be devoted to the care of mental diseases. At about 
this time the Albany General Hospital opened a special division 
for mental disorders, and this probably had an influence in direct- 
ing the movement then showing itself in Michigan. We find 
reference to this in a paper by Dr. Christian presented before the 
Joint Board of Trustees in January, 1901, on "The Movement 
Towards Psychiatric Hospitals and Psychiatric Clinics." In this 
paper, entirely unaware of the movement in which Dr. Herdman 
was interested, he remarked with much foresight : " I believe it 
will be only a question of time before the movement for the psy- 
chiatric hospital will make its appearance in Michigan. It is a 
matter of indifferent concern whether the movement is in con- 
nection with a private or semi-public corporation in a large city or 
with the university." 

It was during the discussion following this paper that the Joint 
Board of Trustees became aware of the progress Dr. Herdman 
had made in his efforts to develop a psychopathic ward in con- 
nection with the university and that at this very time a bill had 
been drafted to secure from the Legislature, then in session, the 
facilities to carry out this plan. This measure was entirely the 
creation of Dr. Herdman. It was due to the personal efforts of 
Dr. Herdman that the measure became enacted into a law and that 
the psychopathic ward was established. 

By this act, under date of May 25, 1901, there was appropriated 
$50,000 for the construction and equipment of a psychopathic 
ward of 40 beds upon the hospital grounds of the University of 
Michigan. It was to be an additional ward of the present Univer- 
sity Hospital and under its management, but the superintendents 
of the several state asylums were to be members of its clinical staff. 
Its business administration was to be under the superintendent of 
the University Hospital, but its medical supervision was to be 
under the head of the department of nervous and mental diseases 
of the universitv. 



270 INSTITUTIONAL CARE OF THE INSANE 

Patients were to be sent to this ward, if the judge of probate, 
during the hearing of an apphcation for commitment to an asylum, 
should be convinced from the report of three examining physicians 
that " there were present in the condition of the patient such 
factors as would render detention in a suitable psychopathic hos- 
pital for a brief period advisable as a precautionary or curative 
measure ; or if the case required the services of specialists trained 
in the treatment of disorders other than those of the nervous sys- 
tem." If the patient recovered he would be discharged ; if not, he 
could be transferred to one of the asylums in the state. It was 
also to be possible for the superintendents of any of the asylums to 
transfer to it any of their patients who might be benefited by the 
facilities for treatment which the general hospital of the university 
possessed. 

As the University of Michigan maintains a department of 
homeopathy the relatives or friends of a patient were free to 
choose the school which should take charge of the treatment, pro- 
vided this did not conflict with the general rules of the regents of 
the university, for the administration of the ward. 

The cost of the maintenance of the patient was to be paid by the 
county in which the patient resided if he were a public charge, and 
if he were to be privately supported, such rates were to be paid 
as the regents of the university should determine. 

There was no mention in the act of any provision for laboratory 
or research work, or of any co-operation with the asylums other 
than in the transferring of patients and afifiliation of the hospital 
superintendents with the staff of the ward in the treatment of 
patients. While there is no specific mention as to the use of 
patients in teaching, it is certain that the existing rules of the 
University Hospital, which provided for the use of any patient 
of the hospital for clinical teaching, also applied to the new ward. 

It was in some ways unfortunate for the immediate success of 
the new organization that the co-operation of the asylum officials 
of the state had not been invited in framing the provisions of the 
act, especially when the asylums were trying to arrange for a 
mutual co-operation in laboratory work. Undoul)tedly this cir- 
cumstance hindered the efforts of the university authorities in 
getting the new organization under way. In turn the situation 
created by the establishment of the psychopathic ward presented 



PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN 27I 

to the asylums possibilities of solving- their difficulties as to the 
centralization of laboratory work, which compelled consideration 
in any further plans they might undertake. 

Not until a year after the passage of the act establishing the 
psychopathic ward was there any mention at the Joint Board meet- 
ings of the new organization. The asylums were still co-operating 
in the arrangements for pathological work made in 1898, but there 
was a general feeling among them that it was far from satisfac- 
tory. The idea was still strong that the work of the institutions 
could best be done in a central laboratory at one of the institutions, 
or in a large city like Detroit, or in connection with the university. 

A careful consideration of the provisions of the act establishing 
the psychopathic ward made it evident that there were many diffi- 
culties to prevent the new organization from working smoothly 
under the laws relating to the insane and in its relation to the asy- 
lum system of the state. The best way to remedy this was to secure 
the co-operation of the asylums in its administration ; and efforts, 
both from the side of the asylums and from the university, were 
active to this end. In July, 1902, a committee of trustees and 
superintendents of the asylums recommended that an affiliation be 
entered into with the proper department of the university at Ann 
Arbor for the study of pathology and for clinical research in 
mental diseases, and that this department be known as the Depart- 
ment of Pathology and Clinical Research of the Michigan Asylums 
and Psychopathic Hospital ; that the central laboratory be located 
at the Psychopathic Hospital with branches at the several asylums ; 
that there be employed an experienced investigator of more than 
local reputation who may be agreed upon by representatives of the 
asylums and university in conference ; that the amount of salary 
and method of payment and all matters of expenditures and the 
details of the plan for affiliation be arranged by the conference 
committee. All arrangements were to be subject to the approval 
of the Joint Board of Trustees. These recommendations were 
adopted and further arrangements were left to a committee com- 
posed of the superintendents of the asylums. On this committee 
were Dr. J. D. Munson, superintendent of the Northern Michigan 
Asylum at Traverse City ; Dr. E. A. Christian, superintendent of 
the Eastern Michigan Asylum at Pontiac ; Dr. W. A. Stone, acting 
superintendent of the Michigan Asylum at Kalamazoo, and Dr. G. 



272 INSTITUTIONAL CARE OF THE INSANE 

L. Chamberlain, superintendent of the Upper Peninsula Hospital 
at Newberry. 

The establishment of the psychopathic ward opened to the 
university an entirely new field of work ; and it could hardly be 
expected that it should at first know definitely how to enter upon 
it. This fact made it difficult for the committee of the asylums to 
conclude any arrangements which were mutually satisfactory. 
The act establishing the psychopathic ward had no provision for 
the appointment of a pathologist such as the asylums were seeking, 
nor was there any provision for the maintenance of laboratory 
work should a mutual arrangement be possible. Further con- 
ferences between the committees made it possible to present to the 
Joint Board of Trustees in July, 1903, the following propositions: 

1. That a laboratory for clinical and research work in insanity shall 
be maintained in connection with the psychopathic ward. 

2. That it be under the charge of an experienced investigator; his 
salary to be paid by the asylums ; his official title to be Associate Pro- 
fessor of Neural Pathology and Pathologist of the State Asylums and 
Director of the Asylums' Laboratories. 

3. The duties of the pathologist shall be to conduct clinical, patho- 
logical and research work in mental diseases in the Psychopathic Hos- 
pital at Ann Arbor and in the state asylums of Michigan. 

4. The asylums are privileged to send members of their staff to the 
central laboratory for clinical and research work. 

5. It was to be possible for any state asylum to transfer cases to the 
Psychopathic Hospital for special study. 

6. The university should annually allow for the support of the labora- 
tory a sum of money at least equal to the salary of the director. 

7. The director of the laboratory was to report to each asylum the 
work accomplished during the year and all work was to be reported as 
from the Michigan asylums' laboratory. 

These propositions did not meet the approval of the Joint Board 
of Trustees and again a plan for affiliation with the university 
came to naught. 

There was no inclination on the part of the asylum officials to 
obstruct the progress of the development of the psychopathic 
ward, but rather the wish was general to affiliate their pathological 
work with the new organization at the university. It was, how- 
ever, felt by many that there was no legal right on the part of the 
asylums to direct any of their funds towards the maintenance of 
an institution so directly a part of the university. As no further 



PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN 273 

progress towards the affiliation seemed possible because of these 
legal objections, the Joint Board postponed indefinitely further 
consideration of the matter. 

The subject was taken up a year later, when Dr. Herdman 
was invited to address the Joint Board on the situation which had 
developed in view of the failure of the asylums to co-operate in 
the new ward, the building of which at this time was nearing 
completion. As it seemed feasible to adjust any legal obstacles 
by legislative enactments, this address secured renewed interest 
on the part of the asylums towards the support of the organization 
at Ann Arbor, and a committee was appointed from the Joint 
Board to arrange for the completion of the building, the appoint- 
ment of a medical director, and the opening of the ward for the 
reception of patients. A few months later the Legislature pro- 
vided for the organization and maintenance of a laboratory in 
connection with the psychopathic ward and for the administra- 
tion of the ward jointly by the Board of Regents and the Joint 
Board of Trustees of the Michigan Asylums. They were to 
appoint " an experienced investigator in clinical psychiatry, who 
shall be placed in charge of the psychopathic ward, whose duty 
it shall be to conduct the clinical and pathological investigations 
therein ; to direct the treatment of such patients as are inmates of 
the psychopathic ward ; to guide and direct the work of clinical and 
pathological research in the several asylums of the state, and to 
instruct the students of the State University in diseases of the 
mind." His official title was Pathologist of the State Asylums. 

By these provisions the university secured the helpful co- 
operation of the state hospitals for the insane, and the institutions 
for the insane acquired a practical plan for a centralized direction 
of their scientific work. 

A joint committee from the Board of Regents of the university 
and from the Joint Board of Trustees of the State Hospitals at 
once took up the administration of the new organization, and in 
September of 1906 they appointed as director of the psychopathic 
ward Dr. Albert M. Barrett, at that time pathologist of the Danvers 
(Massachusetts) Hospital for the Insane and assistant in neural- 
pathology in the Harvard University Medical School. The build- 
ing was completed early in 1906 and on February 7, 1906, it 
received its first patients. 



274 INSTITUTIONAL CARE OF THE INSANE 

It became apparent during the first year's experience in the 
administration of the new institution that there were many diffi- 
culties which had not been foreseen in drafting the statutes for 
its management, and that unless these were revised the smooth 
working of the psychopathic ward as a part of the state organiza- 
tion for the care of the insane was by no means assured. 

Its problems were quite different from those of the General 
Hospital of the university of which it was a part. It seemed best 
to secure for the institution somewhat more independence in its 
organization and administration, but not to lessen its intimate rela- 
tion with the teaching organization of the medical department. 

These conditions made it advisable to enact new statutory pro- 
visions for the organization and administration of the psychopathic 
ward, which was done by the Legislature of 1907. The name of 
the institution was changed to " The State Psychopathic Hospital 
at the University of Michigan." Its relations to the teaching 
facilities of the university remained unchanged, but its adminis- 
tration was placed in charge of a Board of Trustees, which was to 
be composed of four members from the Board of Regents of the 
university and four chosen from the Joint Board of Hospital 
Trustees. The board was given the authority vested by statutes 
in the Boards of Trustees of the State Hospitals for the Insane. 

Its purposes were distinctly defined as a " state hospital, spe- 
cially equipped and administered for the care, observation and 
treatment of insanity and for persons who are afflicted mentally, 
but are not insane." 

The medical director of the hospital by virtue of such position 
was pathologist of the state hospitals for the insane and with 
the approval of the Board of Regents was professor of psychiatry 
in the department of medicine and surgery in the State University, 
to give instruction to the students in diseases of the mind. 

A further provision of the act was that " there shall be main- 
tained as a part of the Psychopathic Hospital at the University of 
Michigan a clinical pathological laboratory, which shall be a cen- 
tral laboratory for the Michigan state hospitals for the insane and 
a laboratory in which research into the phenomena and pathology 
of mental diseases shall be carried on." For the maintenance of 
the laboratory and for the payment of the official salaries of the 
hosi)ital an annual approi)riation was made available. 



PSYCHOPATHIC HOSPITAL AT UNIVERSITY OF MICHIGAN 275 

Within a few months a systematic course of cHnical instruction 
in psychiatry was orj^anized and for the first time an American 
university medical school was provided with a clinic which made 
it possible to give adequate instruction in this branch of medicine. 

A supervisory administration was at once organized in connec- 
tion with the scientific work of the several state hospitals, which 
has since been maintained with earnest co-operation between all 
of the state institutions caring for the insane. 



XL 
THE BOSTON PSYCHOPATHIC HOSPITAL/ 

The most advanced institutions that deal directly with the 
problems of psychiatry in their medical, social and scientific 
aspects are known as psychiatric clinics and psychopathic hos- 
pitals. The idea of the psychiatric clinic appears to be a little 
older and narrower than that of the psychopathic hospital. Traces 
of the idea of a psychiatric clinic are found early in the literature 
of German-speaking countries ; but the completed idea was 
sketched in 1868 by Griesinger, one of the few men of command- 
ing intellects that psychiatry has enjoyed. The idea of a psy- 
chiatric clinic is a university idea, and the current of influence 
runs from instruction and research of a more or less academic 
nature to the practical problems of the insane. 

The term psychopathic hospital appears to be one of American 
coinage ; at least Dannemann, in his account of the Stadtasyl of 
the German system, so states. At all events, the idea of the 
psychopathic hospital is broader than that of the psychiatric clinic, 
and the current of influence which dominates it is likely to be from 
the practical interests of the patients backward upon the university 
medical school. Practically all the newer movements in mental 
hygiene have come from practical alienists rather than from uni- 
versity workers in America. In fact, those who are busy with the 
details of the propaganda for the establishment of psychopathic 
hospitals in the United States of America are troubled by the 
apathy of universities and medical schools in connection not only 
with psychiatry, but with all other disciplines having relation to 
the nervous system, taken as a whole. One influence, however, of 
an important nature has been derived from American universities. 
The great frequency and comparatively well-endowed condition 
of departments of psychology in our country are responsible for 
improvements in mental hygiene, whether in the direction of help- 
ing the individual, helping officials in their tasks or improving 

'This chapter has been furnished by E. E. Southard, M. D., director, 
Psychopathic Hospital ; pathologist, Massachusetts State Board of In- 
sanity ; and Bullard professor of neuropathology. Harvard Medical School. 



THE BOSTON PSYCHOPATHIC HOSPITAL 2,'J'J 

society in general. Massachusetts in especial has enjoyed the 
quite different stimuli of Professors William James and G. Stanley 
Hall, of Harvard and Clark Universities, respectively. 

Those who recall the early development in Massachusetts of the 
conception of a psychopathic hospital must remember many names. 
Pliny Earle in particular, in his address at the laying- of the corner- 
stone of the General Hospital for the Insane of the State of Con- 
necticut, as long ago as 1867, speaks as follows : 

Carbon agglomerated is charcoal. Carbon crystallized is diamond. What 
charcoal is to the diamond, such, I believe, is the psychopathic hospital 
of the present compared with the psychopathic hospital of the future. 
.... When the defects which I have mentioned shall have been thor- 
oughly remedied by a comprehensive curriculum, a complete organization, 
a perfect systematization, an efficient administration, the charcoal now 
just ready to begin the process of crystallization will have become the 
diamond and the world will possess the psychopathic hospital of the future. 

The late Dr. George F. Jelly, medical examiner for the City of 
Boston, for years laid emphasis upon the desirability of such a 
hospital. It took, however, 12 years from Dr. Owen Copy's 
report as executive officer of the State Board of Insanity in 1902 
before the Psychopathic Hospital in Boston became a fact. In the 
year 1915 the Psychopathic Hospital in Boston has already passed 
through its wards more than 5000 different patients, the majority 
of whom have been cases of dubious nature ; that is to say, cases 
that could not properly be adjudged insane forthwith by probate 
courts. 

The hospital has proved an extensive success in Massachusetts, 
and few of the practitioners who employ its devices but wonder 
how the metropolitan district and the state at large ever got on 
without these advantages. It must be stated emphatically, how- 
ever, that the value of a psychopathic hospital, viz., a hospital that 
deals not merely with pronounced insane persons (the " probate 
court" group), but predominently with the psychopathic "not- 
insane," the psychopathic " not-yet-insane," the early and incipient 
cases of mental diseases, and a score of types of mild and doubtful 
psychopathy lying at the base of a certain number of juvenile, 
adolescent and adult delinquencies, is a value which greatly 
depends upon a proper basis in statutory law. So far as I know 
at the present time, only the Commonwealth of Massachusetts and 
the municipality of New York possess laws permitting wide usage 



278 INSTITUTIONAL CARE OF THE INSANE 

of a system by which cases can be brought with the greatest 
facility for temporary care out of the community. New York 
has gone a step farther than Massachusetts in this regard, since 
New York offtcials are enabled to send an ambulance after cases 
requiring temporary care. But a state should be provided not only 
with laws permitting facile disposition of the " temporary-care " 
group, but with proper laws for the admission of voluntary 
patients. A proper law for the admission of voluntary patients 
permits the state to draw upon its treasury for the care of indigent 
voluntary cases. The importance of this provision for the indigent 
voluntaries is mentioned because in a large number of states with 
voluntary admissions the state laws do not inure to the benefit of 
any large number of cases. 

The Psychopathic Hospital has been able to use to the utmost 
the provisions of its " temporary-care " and voluntary-admission 
laws. More than 1000 temporary-care cases are brought into the 
hospital yearly and from 400 to 500 voluntary cases arrive, to say 
nothing of great numbers of out-patients. At present our census 
of out-patients amounts to about 1500 a year. Who could have 
supposed some years since that patients would come in such num- 
bers to a clinic for mental cases and for mental cases only? An 
important feature of the out-patient group, from the standpoint 
of mental hygiene, is that, aside from the after-care group of cases 
referred to the out-patient department (about one-fifth of our 
out-patient census), only about one-quarter of the remainder are 
recommended for institutional care. In short, the dispensary 
feature of the psychopathic hospital does not act like a vacuum 
to draw into the state's institutions all of its patients. 

So much of detailed description is necessary to show what sort 
of institution the founders of the Psychopathic Hospital proposed 
to establish in their propaganda with the public, the Legislature 
and the executive chamber. 

The propaganda was in fact almost entirely non-political ; and 
with the issue of a variety of reports by the State Board of 
Insanity, beginning with the year 1902, it proceeded slowly but 
surely until eventually one of the thriftiest executives of Massa- 
chusetts, the late (iovernor Eben S. Draper, found himself entirely 
willing to support the establishment of a hospital which was to be 
central in location; to cost in the neighborhood of ^$6oo,ooo ; to 



THE BOSTON PSYCHOPATHIC HOSPITAL 279 

contain upwards of 100 beds, and to operate at an expense of 
more than $100,000 a year. It is worth while to reproduce at this 
point the functions of the Psychopathic Hospital as they were 
described in the State Board's annual report for 1910: 

The Psychopathic Hospital should receive all classes of mental patients 
for first care, examination and observation, and provide short, intensive 
treatment of incipient, acute and curable insanity. Its capacity should be 
small, not exceeding such requirement. 

An adequate staff of physicians, investigators and trained workers in 
every department should maintain as high a standard of efficiency as that 
of the best general and special hospitals, or that in any field of medical 
science. 

Ample facilities should be available for the treatment of mental and 
nervous conditions, the clinical study of patients on the wards, and scientific 
investigation in well-equipped laboratories, with a view to prevention and 
cure of mental disease and addition to the knowledge of insanity and 
associated problems. 

Clinical instruction should be given to medical students, the future 
family physicians, who would thus be taught to recognize and treat mental 
disease in its earliest stages, when curative measures avail most. Such 
a hospital, therefore, should be accessible to medical schools, other hos- 
pitals, clinics and laboratories. 

It should be a center of education and training of physicians, nurses, 
investigators and special workers in this and allied fields of work. 

Its out-patient department should afford free consultation to the poor, 
and such advice and medical treatment as would, with the aid of district 
nursing, promote the home care of mental patients. Its social workers 
should facilitate early discharge and after-care of patients, and investigate 
their previous history, habits, home and working conditions and environ- 
ment, heredity and other causes of insanity, and endeavor to apply cor- 
rective and preventive measures. 

The success of the propaganda for the Psychopathic Hospital 
was achieved with the aid of numerous alienists and neurologists 
of Massachusetts, supported by the interest which members of 
the committees of the Legislature and of successive Governors 
took in the matter. I should mention, in addition to Dr. Jelly, 
above named, in the first place Dr. Owen Copp, without whose 
vision doubtless the Psychopathic Hospital would not now exist. 
Dr. Copp was supported in his efforts by the members of the State 
Board of Insanity and of their chairman, Dr. Herbert B. Howard. 
Among others I should mention Dr. Walter Channing, whose quiet 
persuasiveness has often been of avail with legislative committees 
and who was chairman of the trustees of Boston State Hospital at 
the time of the establishment of the Psychopathic Hospital as a 



28o INSTITUTIONAL CARE OF THE INSANE 

department thereof. Committees of the Boston Society of Psy- 
chiatry and Neurology exhibited much activity. Dr. L. \'ernon 
Briggs was able by his energy and resourcefulness to influence 
legislative committees and other persons in such wise as to push 
forward the establishment of the temporary-care provisions and 
the hastening of provision for the Psychopathic Hospital type of 
case. 

Since the opening of the hospital its work has been aided by the 
trustees of the Boston State Hospital and by the State Board of 
Insanity throughout the changes which have occurred in their 
membership. The members of the present Board of Insanity have 
been able to develop the pathological service of the State Board in 
such wise as to help the research function of the Psychopathic 
Hospital to a surprising degree. 

The present Board of Trustees of the Boston State Hospital 
has been especially interested in improvements in administration 
of the hospital which had been at first attempted with too small a 
force, and the efforts of its chairman, President Henry Lefavour, 
have been untiring in this direction. 

I will not consider the statistical feature of the hospital in detail, 
but will present a table showing the tremendous stimulation 
which voluntary admissions have received. My table takes up 
voluntary admissions to all public institutions of Massachusetts 
from the year 1895 to 1913 inclusive. Practically the entire in- 
crease shown by the figures for the year 19 13 is due to the Psy- 
chopathic Hospital. 

VOLUNTARY ADMISSIONS TO PUBLIC INSTITUTIONS OF 
MASSACHUSETTS.' 

Year. No. of Admissions. 

1895-1899 (5 years) 405 

1900-1904 (5 years) 520 

1905 84 

1906 125 

1907 156 

1908 195 

1909 185 

1910 200 

191 1 237 

1912 282 

1913 636 

* Including a large private institution, McLean Hospital. 



XII. 

RESEARCH WORK IN HOSPITALS. 

As has been already indicated, the earHer and most pressing 
work of those who were engaged in the care of the insane was not 
so much to enlarge the boundaries of their knowledge of the 
underlying causes of insanity as to provide shelter and care for 
persons who, unless they secured it, were exposed to serious hard- 
ships, woful privations and permanent mental disability. It is 
therefore not at all strange that special attention at first could not 
be given to the pathology of insanity or to the study of morbid 
cerebral anatomy. 

In 1846 and 1847 three papers on the pathology of insanity 
appeared in Volumes II and III of the American Journal of Insan- 
ity from the pen of Dr. Pliny Earle, who was then in charge of the 
Bloomingdale Asylum, a branch of the New York Hospital. In 
these papers Earle gave excellent clinical histories of several cases 
of insanity which had come to autopsy, with detailed descriptions 
of gross pathological appearances of organs and tissues thus 
obtained. An account was also given of changed vascular con- 
ditions in the brain and an attempt was made to explain them. 
The papers seem to be fully abreast with the pathological knowl- 
edge of that date, which was necessarily largely descriptive in 
character because of the imperfection of apparatus for microscopic 
study and the lack of proper lenses and staining reagents. 

The next papers of any special value as recorded in the meetings 
of the Association and published in the American Journal of 
Insanity were presented by the late Dr. Joseph Workman, of 
Canada, upon the morbid anatomy of general paresis. Although 
the study was a step in the right direction, the results were of no 
great value and could not have been expected to be, in the existing 
state of knowledge. It must be borne in mind too that general 
medical pathology as we now know it did not exist and that 
research workers in every branch of medicine were groping in a 
similar inefficient manner. They knew little or nothing of micro- 
scopical study, and as to pathology were contented to describe 
gross appearances without knowledge of structure, as did Bright 
and Carswell a half century before. 

25 



282 INSTITUTIONAL CARE OF THE INSANE 

The first systematic effort in the United States in connection 
with an institution to study the underlying bodily conditions in 
insanity was initiated by the late Dr. John P. Gray, of Utica, who, 
although not a student of pathology, had large conceptions and 
broad ideas of its importance. He made a report to the managers 
of the Utica State Hospital in 1868 which induced them to 
authorize the temporary appointment of Dr. E. R. Hun as pathol- 
ogist at Utica. In the following year the managers presented in 
their annual report an appeal to the General Assembly for an 
appropriation to maintain a pathological department. It is inter- 
esting to observe the tentative character of the plan and the wisdom 
of it. Up to this time little study had been made of any symptoms 
in the insane beyond deviations from normal conduct, and the 
plan very judiciously set forth the importance of studying the 
accompanying bodily derangements of insanity. It was proposed 
to study bodily secretions and excretions, the state of the pulse 
as revealed by the sphygmograph, the effect of remedies upon the 
pulse, the condition of the cerebral vessels as revealed by the 
ophthalmoscope, the condition of the skin, the morbid conditions 
developed at autopsy, and to portray them by photographs and 
photomicography. The plan as presented may seem haphazard 
and fragmentary, but such also was the condition of all attempts at 
investigation during the barren epoch in the history of medicine 
prior to 1880. The causes of disease seemed wholly mysterious 
and were sought " in the heavens above and in the earth beneath " 
far more frequently than in the human body. Edward R. Hun, a 
young physician and a resident of Albany, but educated abroad, 
was accordingly appointed in 1868 and the fruits of his labors 
may be traced in the annual reports of the Utica State Asylum 
and in the American Journal of Insanity, which was at that time 
edited and published at Utica. He seems to have been industrious 
and painstaking, and, while his researches were not epoch-making, 
they served the useful purpose of keeping the importance of the 
study before the medical profession. He held the position until 
1873, when he resigned to enter upon medical practice and teach- 
ing at Albany. He wrote upon the " Pulse of the Insane " and 
upon " Hc-ematoma Auris." 

The position of pathologist was later filled by Theodore 
Deecke, of Utica, who was a technician rather than a pathologist. 



RESEARCH WORK IN HOSPITALS 283 

He was a good photographer and microscopist and became more 
interested in the photomicography of brain sections than in the 
study of disease. He could make sections, but could not interpret 
them. The sphygmographic and therapeutic studies which had 
been inaugurated by Hun soon fell into the hands of members of 
the regular medical staff and Andrews, Kempster and Kitchen 
gave several excellent papers as the result of them in the Journal 
of Insanity. Dr. John P. Gray, on the other hand, became much 
interested in gross and microscopic pathology and gave a stereop- 
ticon demonstration of his results before the Association at the 
Auburn meeting in 1878. Kitchen failed in health, and resigned ; 
Kempster received an appointment at Oshkosh and Andrews at 
Buffalo and all ceased to do pathological work. 

Deecke soon became interested in lines of commercial work 
which were not closely associated with pathology and for a num- 
ber of years little productive work was done. Dr. Gray failed in 
health and upon his death in 1886 the pathological work was 
practically discontinued. 

The initiative of Utica, however, had been of great value to the 
institutions of the country, and however disappointing the result, 
it is evident that it had demonstrated the need of more specialized 
effort. This came about a few years later when, under the lead of 
Dr. Carlos F. MacDonald, at that time president of the New 
York Lunacy Commission, the New York State Pathological Insti- 
tute was established in New York and Dr. Ira Van Gieson was 
appointed director. Then for the first time in New York an 
attempt was made to study the pathology of insanity in a sys- 
tematic and orderly manner. The Pathological Institute became 
a clearing house for the study of morbid specimens sent to it from 
the different state hospitals and the plan was inaugurated of giving 
instruction to men from these hospitals, who came for definite 
periods of instruction. Dr. Van Gieson, although possessing great 
knowledge and unusual ability, was not fitted by temperament or 
experience to fill the position of director of so large a work, and 
in 1902 he resigned and Dr. Adolf Meyer was made director. 

The State Pathological Institute, which had occupied expensive, 
not to say extravagant, quarters in New York City, was later 
transferred to Ward's Island and began its true work of research 
and education. The training: of members of the staff of state 



284 INSTITUTIONAL CARE OF THE INSANE 

hospitals in history-writing and case-taking, in the study of mental 
disease and in normal and pathological brain structure was begun 
with the effect to improve the medical work in every state hospital. 
Too much cannot be said in praise of the work then initiated, 
which has increased in efficiency each year up to the present 
writing. 

Upon the resignation of Dr. Meyer in 1910, to accept the posi- 
tion of director of the Phipps Psychiatric Institute in Baltimore, 
Dr. August Hoch, former pathologist at the McLean Hospital, 
succeeded him and continued the work. 

Meantime in Massachusetts at McLean Hospital, under the 
leadership of Dr. Edward Cowles, an attempt had been made to 
connect the investigation of mental disease with the growing 
sciences of psychology and neurology on one side, and with the 
study of physiological fatigue and the relations of mental dis- 
orders to bodily metabolism. 

The first work of Dr. W. A. Noyes in 1889 related largely to 
psychology and neurology, and upon his resignation in 1892, Dr. 
August Hoch, his successor, attacked problems of a physiological 
character, involved in the effect of stimulants upon fatigue and 
of the action of remedies, and added to them studies and investiga- 
tions as to Kraepelin's methods. It soon became evident that 
an expert chemist was required for the study of metabolic changes 
and Dr. Otto Folin was added to the staff and made valuable con- 
tributions to methods of study. Later, when he resigned to take 
up work in connection with Harvard University, he was suc- 
ceeded by Dr. S. I. Franz, who had received a special training in 
physiology and was an expert in physiological investigation. Upon 
his resignation, to go to Washington, he was succeeded by Fred- 
erick Lyman Wells in psychology and by Dr. F. H. Packard and 
later by Dr. E. Stanley Abbott in pathology. 

The work accomplished at McLean has been of a high character 
and of wide-reaching importance. 

Meantime the initiative of McLean had borne fruit in several 
state institutions, notably at Worcester and Danvers. At the for- 
mer Dr. Adolf Meyer was appointed pathologist in 1896 and gave 
valuable assistance in reorganizing the medical work and perfect- 
ing methods of pathological investigation. 



RESEARCH WORK IN HOSPITALS 285 

Upon his transfer to the New York State Psychiatric Institute 
in 1902 the special work of a pathologist was assumed by the 
pathologist of the State Board of Insanity. 

A similar work was undertaken at Danvers by Dr. W. L. Wor- 
cester and continued after his death by Dr. A. M. Barrett, but 
upon the transfer of the latter to the State Psychopathic Hospital 
at Ann Arbor the work was taken over by Dr. E. E. Southard, 
who was later made State Pathologist. 

Useful pathological work has also been done by Dr. S. C. Fuller 
in connection with the Westborough State Hospital. Valuable 
pathological investigations have also been made in other states, 
notably in Rhode Island by Drs. William McDonald and Farnell ; 
in Indiana under Drs. Edenharter and Potter ; in Illinois under 
Drs. Adolf Meyer, Stearns, Podstata, Singer and others ; in Ohio 
at Massillon under O'Brien ; in New Jersey under Drs. Cotton, 
Prout, Hammond and others ; at the Government Hospital at 
Washington under Drs. Blackburn and Franz ; in Pennsylvania by 
Drs. Mitchell and Orton ; and in New York quite generally in all 
the state hospitals, so that the outlook for future fruitful path- 
ological investigations seems bright. 



CHAPTER VII 

TRAINING OF NURSES AND ATTENDANTS 



I. 

TRAINING SCHOOLS FOR NURSES AND THE FIRST 
SCHOOL IN McLEAN HOSPITAL/ 

The history of nursing in hospitals for mental diseases in the 
United States had its beginning in its first asylums. In these were 
adopted the principles of the great reform in the care of the insane 
begun contemporaneously by Pinel and Tuke. But while the prin- 
ciples of humane care were making slow progress in the long estab- 
lished institutions of the older countries, their general adoption 
in all the new asylums in America gave that country the leadership 
for a number of years in the reform which included the practice 
of the principles of intelligent and sympathetic attendance upon 
the insane. It is of great interest and importance to note here the 
earlier events in this great general reform in the care of the insane, 
for in them we find the origins and the conditions out of which 
came the special reform of nursing. 

The influence of the teachings of Pinel and Tuke wrought pro- 
found changes and became prevalent by the end of the first half 
of the nineteenth century. In Europe the work of Esquirol sus- 
tained that of Pinel; Jacobi visited the Retreat at York, and his 
writings reflect most largely the spirit of the English reform; 
Fliedner was a neighbor of Jacobi, at only twelve miles distance, 
whose work had been going on eleven years, when Fliedner in- 
cluded in his purpose the care of the insane, and re-established the 
nursing sisterhoods in the Protestant church following the his- 
toric example of the Catholic orders. The later expression of the 
beginnings at the York Retreat was given by the work and 
writings of Samuel Tuke, who republished those of Jacobi, and 
Charlesworth, Hill and Connolly. 

In the United States, the examples of the older countries 
having been adopted, the prevalence of the reform was general 

* By Edward Cowles, M. D., formerly superintendent of McLean 
Hospital. 



290 INSTITUTIONAL CARE OF THE INSANE 

and earlier. By the end of the second decade Rush had written in 
the most humane spirit ; the institution at WiUiamsburg, in Vir- 
ginia, another in connection with the New York Hospital, and the 
Frankford Asylum, as an offshoot of the York Retreat, had been 
established; as also the McLean Asylum, where Wyman put in 
practice the modern spirit of humane attendance. At the latter 
place, in the notable fourth decade, contemporary with Jacobi and 
Fliedner in Germany, Bell published his " Directions for Attend- 
ants," and Woodward, at the Worcester Asylum, a similar 
treatise. This was prior to the publication in England of the 
" Teachings for Attendants," by Connolly, whose contemporaries 
within the next ten years in the United States — Kirkbride, Curwen, 
Ray and others — had great influence by their work and writings in 
advancing the humane care of the insane in the considerable num- 
ber of asylums which by that time had been built throughout the 
country. 

This brief reference to the history of the great movement in 
the first half of the last century, with little more than a recital of 
notable names familiar to every modern alienist, is sufificient to 
indicate the intensity of interest and greatness of effort, in which 
many joined to reform the care of the insane. In Prussia, Eng- 
land and America there was early recognition of the prime need 
of persons of intelligence and goodness of character who could be 
interested in the nursing of the insane. In all these countries there 
were throughout the half century many attempts to establish a 
system of training such nurses, but little was accomplished beyond 
the improvement of the individual excellence of the ordinary 
attendant. Yet, notwithstanding the failure to devise methods of 
systematic training, it is plain that the leadership in the recognition 
of the essential requirements of the nursing of the sick and the 
insane, and the efforts to supply the need, belonged to the alienists. 
There was no such effort in the general hospitals until the teaching 
of Florence Nightingale created the great epoch of reform in 
them. But, although the leadership in nursing-reform passed 
over to the general hospitals, it was no doubt inspired in part by 
the example of the work among the insane which was well known 
when Florence Nightingale went to visit Pastor Fliedner at Kais- 
ers werth in 1849. 



TRAINING SCHOOLS FOR NURSES 29I 

The first thirty years of the last half century, coming down to 
1880, witnessed the development of Florence Nightingale's reform ; 
it came to the United States from England in the years 1866 to 
1873, soon after the founding of the first training school at St. 
Thomas' hospital in i860. The improvement in the care of the 
insane in the asylums and hospitals had taken the lead in the latter 
country, but in both the success of the training of women for 
general nursing had a stimulating influence to new efiforts by the 
alienists. 

The spirit of the time was well expressed in the report for 1859 
of the Commissioners of Lunacy in England, in which the impor- 
tant question of nursing and attendants for the insane was made a 
special subject for comment and inquiry as "one to which for 
many years they had steadily directed their attention " ; and they 
endeavored to " impress upon all who are responsible for the care 
and treatment of the insane the paramount duty of adopting means 
for securing the services of competent attendants." When the 
commissioners reissued, in 1879, their former circular letter, it 
was declared that " although the care and treatment of the insane 
have, in most respects, altered greatly for the better, improvement 
in the character and position of attendants has not been nearly so 
marked." It was early in this period of thirty years that Browne, 
at the Crichton Institute, made historic the well-known event of 
" the first attempt to educate the attendants upon the insane " 
by a course of thirty lectures in 1854, the very year of Florence 
Nightingale's going to the Crimea ; it was near the end of this 
period, in 1876, that Clouston read, before the British Medico- 
Psychological Association, his notable paper in which he lamented 
the unattainableness of the ideal asylum attendants, and made 
the significant comment that we cannot " expect to get persons 
to act as attendants from the (so-called) higher motives" in 
the absence of inducements to worthy persons to engage in the 
delicate duties of nursing. Noting also the inequality and the 
common absence of the necessary instruction, he asked, " Can 
we not devise and elaborate a systematic professional training 
for attendants in all our large asylums ? " It is noteworthy that 
thoughtful alienists had long recognized the inadequacy of the 
higher motives alone to attract worthy persons to this service; 
Jacobi and Samuel Tuke believed that a sufficient supply of such 



292 INSTITUTIONAL CARE OF THE INSANE 

persons could not be procured. Thus it was that the alienists 
were for a long time the first to know what was wanted for good 
attendants upon the sick and the insane, but, as late as 1880, they 
had not learned the secret of Florence Nightingale's success. 

Before passing from this formative period of modern nursing- 
reform, it should be noted that one of the first effects upon the 
alienists was to attract attention to the employment of women in 
men's wards. In England married women were used as " bed- 
makers " ; in Scotland Batty Tuke had " lady-companions " for his 
patients of the private class, and Clouston successfully established 
infirmary wards in charge of women nurses. Yet, in 1880 ther6 
did not exist anywhere in the world, outside of the religious orders, 
a definitely and permanently organized school for the systematic 
professional training of nurses for the insane. There had been 
many attempts, especially during the previous ten years ; they were 
generally a few lectures, given by a medical superintendent, or 
sometimes an assistant medical officer of an institution ; or a course 
of lectures might be once or twice repeated in successive years, 
and then cease wholly because of the departure of the single person 
upon whom the instruction depended, or through his failing zeal 
due to the frequent changes among the attendants and the absence 
of any apparent improvement in the service. It came to be said 
that there was no proper place or material for the training of 
nurses in the general wards of a hospital for the insane. Many 
believed it would be impossible to get young women, of the class 
who sought the general hospital schools, to become interested in 
work with the insane ; also that, if a system of instruction could be 
made successful, the nurses would then leave the service, and the 
increased labor of medical officers in teaching would be wasted. 

In the United States, in 1880, the conditions with respect to the 
problem of nursing for the insane had come to be much the same 
as in the mother country under the influence of the great reform 
in the general hospitals. It is necessary to review these prior con- 
ditions in order to trace their formative influence in the next event 
in this history, which was the permanent establishment of a train- 
ing school for nurses at the McLean Hospital (then Asylum), the 
first formally organized school in any hospital for mental diseases. 

The employment of women as nurses in the British Army in 
the Crimea conflicted with the organized methods of the military 



TRAINING SCHOOLS FOR NURSES 293 

service and met at first with considerable opposition. The estab- 
lishment of training schools in general hospitals also had to over- 
come objections from visiting physicians and surgeons who pre- 
ferred the old regime. All were soon convinced of the great 
improvement in eflFected nursing ; but so far as is known no general 
hospital prior to 1878 of its own initiative had established such a 
school. The Boston City Hospital school was established in that 
year. The school at St. Thomas Hospital and all others previous 
to that of the Boston City Hospital were organized outside the 
hospitals, to which they furnished nursing, and were financed by 
private benevolence. But there is a limit to such benevolence. The 
schools themselves as a rule could not be self-supporting, for there 
is little demand for the services of one that charges even a moder- 
ate fee for board and tuition. There is no pecuniary profit in the 
business of education, and had we then continued to be dependent, 
though only in part, on charity for their instruction, the supply of 
nurses would indeed be limited. There could be only a few schools 
and these in the largest cities. But private enterprise having fur- 
nished the means for demonstrating the value of the work, it has 
been the privilege of the hospitals themselves to take it up and 
greatly extend it. Only the desire of hospitals to improve the nurs- 
ing service for their patients and their willmgness to enter the field 
of education have made possible a most honorable profession for 
so many young men and women with a fair preliminary education. 
The Boston City Hospital was the second general hospital to 
have a medical superintendent, the Massachusetts General Hospital 
where one of the first training schools in America was established 
in 1873 having been the first. It was not practicable to organize 
for the City Hospital a like association of benevolent persons to 
support a school for its nurses. It had required some years of 
discipline and gradual preparation to improve the character of the 
service to make it fit for training ; and it was believed that the best 
results could be gained by keeping the nursing service as a regular 
department of the hospital. This plan was adopted with the 
approval of the trustees; the first class was made up of the best 
nurses already a number of years in the service with others who 
entered it later and were promised a course of training. The ven- 
ture was made immediately successful by Linda Richards as super- 
intendent of nurses and matron of the hospital. The form of 



294 INSTITUTIONAL CARE OF THE INSANE 

organization under a medical superintendent proving possible in 
two hospitals, it afterwards became general in institutions of all 
kinds and degrees, with physicians in the larger hospitals and 
trained nurses in the smaller ones. Such medical reorganization 
had a deeper purport than the participants in it knew. It meant 
adapting such experience as is gained in military hospital train- 
ing to the management of a medical business in a civil hospital, 
thus creating a unified authority able to regard the service to 
the sick as the prime object and to make contributive to it all 
other interests. But while all these internal interests were inci- 
dental to the main purpose, efficiency demanded harmony of co- 
operation ; this meant a thoughtful and just regard for the physi- 
cal, mental, moral, social, and domestic interests of the various 
individuals^ — men and women, older and younger, in a great 
human family under one roof. Out of the welding together of all 
such interests and activities there comes unity of purpose and 
directness of aim. that make accomplishment simply a logical 
sequence. 

The McLean Hospital, two years later, like all hospitals for the 
insane, had the same complex conditions of service and social life, 
only in a far more emphatic form. In this regard indeed, at that 
time, the asylums had the advantage over the general hospitals of 
having resident physicians in charge ; this had been the rule with 
few exceptions since their early days, beginning with Wyman of 
McLean in 1818, and it was this that gave America the leadership 
till the middle of the century when, through the long contested 
administration-reform, the English institutions had become gener- 
ally free of the domination by wardens and keepers inherited from 
the prison system of the i8th century. Thus it was that in 1880 
the asylums had long been in a better condition for nursing reform 
than the general hospitals ; by reason of the fact of having medical 
superintendents. This fact was due to the established recognition 
of the essential difference between the two types of institutions — 
in the general hospitals the patients are comparatively transient 
subjects of care and treatment — sane and orderly in behavior; in 
the asylums the patients are longer resident in the most favorable 
cases, and for the most part they are comparatively permanent 
inmates of a socially organized household that becomes responsible 
for constant supervision of their mental and moral welfare, and 



TRAINING SCHOOLS FOR NURSES 295 

protection against emergencies. Progress in treatment requires 
constant attention to their social relations ; and the test of long 
experience proves the essential need of attendance by a resident 
staff. It was under such conditions that, in regard to their proper 
medical organization and control, the asylums were better hos- 
pitalized with the conditions of progress than the general hospitals 
themselves. Thus tracing the history of the transition it was only 
necessary to transfer the previous special experience gained in the 
City Hospital and adapt it to establishing a school for nurses in a 
hospital for the insane. In the practical interest of the nurse the 
most essential principles involved had been found to demand two 
requirements : ( i ) To give the nurse, in fair exchange for her 
service, a respectable profession, remunerative enough to satisfy 
her wholesome interest in provision for the future of herself and 
often of others likely to become dependent upon her ; (2) To stimu- 
late the natural motherliness of the nurse, through which her 
womanly sympathy is at once enlisted, by teaching her what to do 
to relieve bodily and mental suffering. It was recognized that the 
scope of every plan of teaching had been too limited ; it did not go 
beyond the idea of improving the attendance upon the patients 
immediately concerned. 

Beginning with the year 1880, the first step at the McLean 
Hospital was to introduce into the attendants' work the regular 
methods of the wards of a general hospital — the " manipulations of 
nursing," in all possible ways. The " attendants " were called 
nurses, and the " boarders " patients. To stimulate the expectation 
of profitable employment in private nursing, nearly fifty nurses, 
in the years 1880-5, were allowed leave of absence from time to 
time to attend private cases. While the instruction was being car- 
ried on by these preliminary methods, the study of the situation led 
to the conclusion that the perpetuity of the work depended upon 
its having a definite organization by placing the school under the 
charge of a special superintendent, to carry on the substantial part 
of the teaching, and to maintain with her assistants an organized 
system. Such an organization was made formal at the McLean 
Hospital in 1882, the date to which the founding of the school is 
assigned; the processes of development were a continuance, how- 
ever, on the same lines as before actually begun in 1880; there 
were no lectures till later, the continuity of the system of instruc- 



296 INSTITUTIONAL CARE OF THE INSANE 

tion with its necessary details being mainly sustained by services 
other than those of the physicians ; the training of instructors was 
needed. Women trained in general nursing had already been 
employed in two or three men's wards by Dr. Jelly, in 1877, with 
duties much like those of companions. Early in the development 
of the system of training, experienced nurses from the women's 
department of the hospital were placed in men's wards, in charge 
of all the duties belonging to the "mistress of a household," and 
with them other young women as ward maids, in the manner of 
the service of a ward in a general hospital. This plan was entirely 
successful and most beneficial in its efYects. 

Another most essential conclusion was reached during this period 
of the gradual development of the school. It came to be believed 
that there would be no adequate field for the professional employ- 
ment of the product of the school as specialist nurses in the public 
service. It was determined therefore to give the pupil nurses a 
course of instruction covering as much as possible that of a general 
hospital training. In a comparatively small hospital like McLean 
this seemed difficult at the outset, but it was held that in the large 
hospital for the insane, with the possibility of special " infirmary " 
and " hospital " wards, there would be sufficient material for 
instruction in the practice as well as the principles of general nurs- 
ing. In 1884 the essential methods of instruction had become well 
determined and established — also the probability of a considerable 
demand for the nurses so trained ; then regular courses of weekly 
lectures for senior and junior classes were begun by the medical 
staff and continued during eight months of the school year. The 
special exercises heretofore conducted by the superintendent of 
nurses and her assistants were further developed, with instruction 
in surgical " first-aid," etc., by assistant physicians. The work of 
a full curriculum of two years was then in full operation and con- 
tinued without interruption thereafter; the instruction was largely 
devoted to general nursing with constant reference to the applica- 
tion of principles and methods to the nursing of the insane. The 
women graduates who chose to do so were permitted to take 
an additional year of training at the Massachusetts General Hos- 
pital. Early in 1886 five nurses were graduated who had been 
from three to four years under training ; later in the year 10 others 
made the total product of the year 15 nurses. Classes of men were 



TRAINING SCHOOLS FOR NURSES 297 

begun in 1886; and in 1890 the product of the school in graduates 
aggregated 70 women and 22 men. In the latter year only 22 of 
the graduates remained in the service; but the general success of 
those who had gone out had great influence in giving the school a 
standard of attractiveness, ever after maintained. 

The establishment of other schools came immediately after that 
of the McLean Hospital. Following its class of 1886, a class was 
graduated at the Buffalo Hospital, under Granger's instruction, 
chiefly in lectures by himself in a course of two years; in that year 
three schools were newly established, respectively, by Wise, Dewey, 
and Hinckley ; they were followed in 1888 by Bancroft, and in 1889 
by Page. By 1906, 62 schools in hospitals for the insane could be 
enumerated. While their requirements had not the uniformity 
that could be desired, there has been great advancement in that 
regard : the tendency is to increase the course of training to three 
years, and to keep up with the progress in the general hospitals. As 
in the McLean Hospital school, there has been a positive tendency 
in all the succeeding ones to qualify the graduates for general 
nursing, on the principle that requires the medical student intend- 
ing to be a specialist to ground himself in the general knowledge 
of his profession. Experience has shown that, in this combination 
of training, these factors do not conflict; the primary and most 
general requisite in the nurse is perfection in her personal relations 
with the patient, and this is best attained in mental nursing ; even 
though the nurse should ultimately prefer bodily nursing she does 
not forget the former when it is followed by the really specialist 
training in the care of surgical and medical cases in a hospital for 
" general " diseases. The personal training is the most general. 
This characteristic of the insane hospital training schools in the 
United States, differing radically in this regard from the British 
system, stimulates and promotes the strong movement that has 
been going on in them toward a more complete hospitalization of 
the institutions themselves. The broader training of the nurses 
reacts upon the instructor ; he who teaches learns. While the inter- 
est of physicians in the hospitals in surgery and general medicine 
is not unique here, it is probably more general. The increase has 
been notable during the last fifteen years in the provision made for 
the surgical treatment of the insane in the large institutions, not 
only in respect to gynecological surgery but for the relief of all 
26 



298 INSTITUTIONAL CARE OF THE INSANE 

remediable conditions ; the well-furnished " surgery " is more com- 
mon. The broader training of the nurse is both a consequence and 
an aid — a supply creating a demand. 

Summary. 

In the United States the history of nursing in the hospitals for 
the insane includes that of humane attendance, which was an essen- 
tial part of the great reform of Pinel and Tuke. These hospitals 
were in advance of the general hospitals during the first half cen- 
tury, on both continents, through the earnest and constant efforts 
of the alienists to give the insane the kind of intelligent and sym- 
pathetic personal service that springs from the higher motives ; 
but little improvement was made beyond the grade of " ordinary 
attendants.'' In the third quarter of the century nursing reform 
was established, and widely extended in the general hospitals by 
educating the nurse and giving her a respectable profession. This 
proved, as a sequence perhaps not foreseen by Miss Nightingale, 
to be remunerative in private life and an inducement to attract 
worthy persons to the service of the general hospitals. A concur- 
rent advancement was not gained for the insane, in the quarter- 
century 1850 to 1875, in spite of the renewed efforts of the alienists, 
because they did not see the way to offer a like inducement ; their 
attempts were aimed too much at creating a specialist attendant 
for their own service, without sufficient provision for training a 
nurse qualified for the public service beyond the narrow scope of 
mental nursing. This was the situation both in the United States 
and older countries, a little later than the beginning of the last 
quarter-century. 

The success of the effort in the United States begun in 1880, 
resulting in the permanent establishment of a training school for 
nurses for the insane, was gained by the accomplishment of two 
definitely planned purposes : ( i ) By organizing a school with a 
sufficient staff of teachers and officers to insure its perpetuity and 
enable it to offer an adequate course of training to lead to a pro- 
fession. (2) By insisting upon giving a broad training to qualify 
the pupil for general nursing ; it was the proven success of this 
that determined the larger usefulness and ready employment of 
the nurse in the public service. The hospital lost nothing by 
making it worth something to the nurse to come to it. These two 



TRAINING SCHOOLS FOR NURSES 299 

provisions appear to have been the most potent factors in bridging 
the long existing difficuhy that stayed the progress of the ahenists. 
It was on such foundations that, in twenty years, sixty-two schools 
were established, upon the independent initiative of their founders. 

The result is that the adoption of a plan of training with such 
a scope is contributing to the more rapid and complete hospitaliza- 
tion of the institutions for the insane in the United States. These 
schools possess a power of growth, and by maintaining their kin- 
ship in the broad field of general medicine they are themselves 
stimulated to keep pace with the advancement in the general hos- 
pital schools. Many of the nurses from the former go for a time to 
a general hospital to specialize in surgery, etc. ; or to lying-in or 
other hospitals. With the increasing practice in the schools of 
employing nurses from other schools, there is freedom for the 
adaptation of the nurse to her calling according to her personal 
qualifications and inclinations, much like that of the medical stu- 
dent. The disposition of the " nursing world " to relegate the 
" mental nurse " to an isolated, specialist class has failed ; she has 
won her place, and is now recognized by the organized associations 
as having the standing of a nurse, when properly trained. All 
these things help to raise and hold up the standard of the schools 
for nursing in hospitals for the insane. 

Great interest belongs to the tracing of the factors of develop- 
ment of these schools for nursing; they are grow-ing up to their 
contributive place in the great movement in those hospitals which 
is surely leading ultimately, not to heroic surgery to cure insanity, 
but to the recognition and relief of all diseases that afflict the insane, 
making the field of psychiatry as broad as that of general medicine. 
Yet this history of modern nursing reform is but one of the many 
aspects revealed in a still broader view of the march of progress 
in this field of personal service for the weaker half of humanity, 
in many lines concurrent with nursing reform. Having found a 
common aim they tend to merge, though at first having little seem- 
ing kinship. Beginning as a modern movement in the field of relig- 
ious effort, social service in the larger conception of its province 
has come to include many formerly separate forms of philanthropic 
service. For many years there have been out-patient services 
for mental disorders, and organized methods for " after-care " 
and ■' boarding-out." and trial " visits " at home in convalescence. 



300 INSTITUTIONAL CARE OF THE INSANE 

The great expansion in recent years of social service work in 
general hospitals is making them more perfectly hospitalized in 
all their departments, and there is a like uplift and new inspiratio.i 
in the early care of the insane through the remarkable development 
of the new psychopathic institutions with their higher order of 
attainment ; they are the outcome of forces long at work — the 
culmination of efforts to gain long desired needs in psychiatry. 
Thus the improving care of the mentally sick, being brought on 
its own part to a higher level of hospitalization, is calculated to 
return reciprocal aid in a great unifying extension of social ser- 
vice, through the qualifications of educated women that have been 
gained in mental nursing. In the working together for good of 
all these forces not only is there a recognition of a larger place for 
psychiatry in general medicine, but also of its own share in the 
highest service of preventive medicine. 



II. 

FIRST TRAINING SCHOOL FOR ATTENDANTS AT 

THE BUFFALO STATE HOSPITAL (ASYLUM), 

1883-1886/ 

In the year 1883 instruction of women attendants at the Buffalo 
State Asylum, now the Buffalo State Hospital, was begun. At 
first it was a general instruction upon the rules, and more partic- 
ularly upon the care of the insane. It was experimental in char- 
acter, but with hopes that a regular training school might be 
organized. When it soon appeared that there was a true interest, 
a class of women was formed and a regular course of instruction 
was adopted. 

In 1885 a similar regular instruction was begun for men attend- 
ants. In 1885 the Board of Managers gave ofificial recognition to 
the school and a circular was printed setting forth its object, the 
instruction given, the qualifications necessary for admission and 
the privileges received. It stated : " All attendants shall be in- 
structed in the rules and regulations of the asylum, and in the 
duties of their several positions. The special training of the school 
will be given in such studies and methods for the special work 
of attendants upon the insane and for nursing the sick. The course 
will be two years, and will consist of lectures and clinical instruc- 
tions." 

All applicants w^ere required to pass a state civil service examina- 
tion and to undergo a probationary period of two months. 

There was to be an examination at the end of the first and second 
years, and it was provided that the attendants, if qualified, " shall 
receive a certificate from the institution as well-qualified nurses 
and attendants upon the insane." 

Dr. J. B. Andrews, the superintendent, in his report of 1885, 
says : " Thus was inaugurated the first training school established 
in any state asylum for the insane in this country, and the only one 

^ By William D. Granger, M. D., Vernon House, Bronxville, N. Y. 



302 INSTITUTIONAL CARE OF THE INSANE 

of which we have any knowledge that provides for the instruction 
of both men and women attendants." 

The State Board of Charities of the State of New York by 
resolution cordially approved and commended the action of the 
managers of the Buffalo State Asylum and the plan of instruction 
outlined in their circular, and regarded the establishment of the 
school as the beginning of a new era in the selection and proper 
qualification of attendants upon the insane. 

An eflfort was made to give instruction to every attendant, and 
in 1885 all men and women attendants but two were members of 
the school. 

On April 30, 1886, a class of seven was graduated.' This 
followed an examination held in the presence of the president 
and the two medical members of the Board of Managers. There 
were six sets of questions, viz., upon the nervous system, the mind 
and mental phenomena, midwifery and monthly nursing, epilepsy, 
insanity and the care of the insane, general medicine and drugs. 
The address was given by Dr. Stephen Smith, State Commissioner 
in Lunacy. Hon. William P. Letchworth, president of the New 
York State Board of Charities, Rt. Rev. Bishop Ryan, and many 
professional men and others from Bufifalo, interested in the move- 
ment, were present. Papers were read by graduates on the follow- 
ing topics : " The V^alue of Regular Administration of Food," 
" Hallucinations and Illusions Among the Insane," " The Relation 
of Attendants to Patients." 

Ample extracts from these papers are to be found in the Journal 
of Insanity, July, 1886, together with many of the questions asked 
in the examination and Dr. Smith's address. 1 he pa|>ers of the 
graduates were honest efforts, creditable to the writers, and who- 
ever reads them will acknowledge that they compare favorably 
with any that can now be produced. I was able to follow the after 
life of several of the graduates. They were fine women and were 
most successful in their nursing career, while they freely bore testi- 
mony to the great value of their training as fitting them for their 
calling, developing their character and their conception of the 
dignity of their work as nurses. 

' Dr. A. W. Hurd, now superintendent, then second assistant, was asso 
elated in the instruction of this class. 



FIRST TRAINING SCHOOL FOR ATTENDANTS 303 

The following are some of the questions asked : 

Insanity (38 questions). 

Give some of the physical conditions of acute mania; of acute 
melancholia ; detail the care such patients need. What is a delu- 
sion ; an insane delusion ; a fixed delusion ; delusions of suspicion ? 
What are hallucinations; illusions? What patients are likely to 
choke themselves? 

Epilepsy (15 questions). 

W^hat are characteristics of a fit? Conditions liable to follow 
a fit ? What is to be done in a fit ? 

General Questions (41 questions). 

W'hat is asphyxia ? What should be done in drowning, hanging, 
suffocation? How is artificial respiration performed? Give 
method of applying moist heat — a turpentine stupe fomenta- 
tion — poultices — a mustard plaster. What is a deodorizer ; an 
antiseptic, and a disinfectant? Give apothecary's weights; dose 
of powdered opium ; tincture of opium, morphine ; symptoms 
and treatment of opium poisoning ; after what injuries should alco- 
hol be avoided? 

Aside from his office as commissioner. Dr. Smith was singularly 
qualified to speak. He was a successful surgeon in New York City 
and had been for years a teacher in a metropolitan medical school : 
he was connected as visiting surgeon with general hospitals, 
and especially had been identified with the establishment of the 
newly created training school at Bellevue Hospital. He also pos- 
sessed exceptional knowledge and experience. He had an intimate 
knowledge of the kind of nurse (so-called) employed in general 
hospitals before the day of training schools and he had witnessed 
the establishment and development of training schools. He was 
also well acquainted with the untrained asylum attendant ; he had 
watched our efiforts at Buffalo most carefully, and he knew the 
graduates personally. 

Dr. Smith in opening said : " When I began my official inspection 
of the institutions for the insane, I entertained no friendly opinion 
towards their management. And especially did I regard the at- 
tendants as a class of men and women probably much below the 
average nurses in hospitals with which I am connected. I would 
be recreant to my sense of justice did I not in this place bear willing 
and emphatic testimony to the general good character of the at- 



304 INSTITUTIONAL CARE OF THE INSANE 

tendants in the asylums. I have seen them in every capacity and 
tested them by every suitable method day and night, and I know of 
no class of employees who could have better sustained the 
scrutiny. 

" In the care of the sick aptitude for nursing has hitherto been 
regarded as the only qualification. But within ten years to apti- 
tude has been added training by a systematic course of instruction, 
and the result is the old-grade nurse has been completely driven 
from the field. And if the nurse of one sick of a physical disease 
is so much improved by training, how infinitely more important 
it it that those who are to administer to a mind diseased should have 
special training. I cannot, therefore, too much commend this first 
effort to thoroughly prepare attendants for their duties. In fact, 
I have no doubt that within a decade no attendant will be employed 
in a state asylum in this state who has not certificates from a train- 
ing school." 

To the managers he said : " To be pioneer of a far-reaching 
reform, not only in the original conception of its underlying prin- 
ciples, but in the organization and perfection of the scheme by 
which its benefits are to be secured, is the highest honor to which 
man can attain. It is, then, with no ordinary pleasure, and with a 
profound sense of duty, that in this public capacity and on this 
auspicious occasion, I acknowledge the obligation of the state, of 
every citizen interested in the best care of the insane, and of the 
insane themselves, to the founders and promoters of this school." 

It was no small undertaking to establish such a training school 
in 1883. Training schools for nurses in general hospitals had not 
then fully passed their first stage, and for one in an insane asylum 
there was no guide. Fortunately, we did not make a plan ; we 
simply began by testing ourselves and the attendants for the first 
year. In this way we were able to establish systematic training 
and in two years to instruct and graduate a class. 

In 1883 Dr. W. G. Thompson published a small book of 57 
pages, " Training Schools for Nurses," Putnam. The first part of 
the book is a description of the old and new system, a defense 
against the " opposition to the new system," and a description of 
what a training school is, and what a trained nurse is or should be. 
At the time of publication there were 23 training schools in the 
country, some just established. Several schools not connected with 



FIRST TRAINING SCHOOL FOR ATTENDANTS 305 

any hospital were established in different cities and instruction 
given, while an effort was made to secure practical work in hos- 
pitals. Only 1 1 schools in general hospitals had graduated nurses 
and the total number of graduates was less than 600. These 
schools, with graduates directly connected with general hospitals, 
were either in New England or in New York State. The require- 
ments were a good common school education, reasonable age, and, 
of course, good character. Instruction was from 18 months to 2 
years. Unfortunately schools were pressed for money and during 
the second year nurses were sent out to do private nursing, thereby 
losing much instruction but turning into the schools a good many 
thousand dollars thus earned. Nurses in training were paid $5 to 
$15 a month, besides being given board and lodging. Two or three 
hospitals only had special homes and most schools had to adopt any 
make-shift to give living quarters. Many wards were without 
nurses from the school, and nursing on men's wards was little 
practiced and the desirability of it even questioned. 

Two text books of instruction only had been published. One 
was "A Hand-Book of Nursing," published " under the direction 
of the Training School for Nurses, State Hospital, New Haven," 
1882 ; the author's name was not given, but introductions had been 
supplied by Presidents Porter and Woolsey of Yale College. The 
other was, " A Manual of Nursing for the Training School for 
Nurses Attached to Bellevue Hospital," 1882. In the preface it is 
stated that " the credit of editing and compiling belongs to Dr. 
Victoria White." Miss Clara Weeks' book was published in 1885. 
These books were elementary in construction, and covered about 
all forms of nursing, except that of insanity and nervous diseases. 
At the present time they would be called primers. They were 
sufficient for their day, and, though small, were works of great 
excellence. 

These pioneer schools did thoroughly good work under great 
difficulties, and graduated well trained nurses. In so far as we 
could find out their ways and methods, they served as our guides, 
but they were far from being established and systematized, as are 
the schools at the present time, and it was difficult to obtain 
accurate information regarding them. 

Dr. Smith's prediction that within a decade no attendant would 
be employed in a state asylum in New York who had not certificates 



306 INSTITUTIONAL CARE OF THE INSANE 

from a training school, was not fulfilled. I always believed that 
had our New York institutions remained as when he spoke all 
attendants would, as he said, be in training or graduates. But with 
the coming of state care, the many problems to be solved, more 
pressing than training, and the rapid increase in the number of the 
insane in different hospitals, prevented the fulfillment of this hope. 

I would call attention to the circular of the managers. In this it 
will be seen that the plan was to give a course of instruction to 
those not entering the training school. " All attendants," it reads, 
" shall be instructed in the rules and regulations and in the duties 
of their several positions." In addition the training school was 
established. A full course of instruction was established for 
attendants with good results. I have always advocated that in the 
establishment of training schools the attendants should not be 
neglected. That they will respond to such instruction and be 
greatly improved by it, I know from experience, while the benefits 
to the hospital go without saying. 

During the three formative years of this school three text books 
for attendants were issued. The first was a " Handbook for the 
Instruction of Attendants on the Insane," 1884. It was prepared 
by a committee of the British Medico-Psychological Association, 
Dr. A. Campbell Clark being the " Convener of the Committee." 
Another was " Lectures on the Care and Treatment of the Insane, 
for the Instruction of Attendants and Nurses." By W. C. Wil- 
liams, M. D., Sydney, X. S. W., Government Printer, 1885. The 
third, by the writer of this article, was " How to Care for the 
Insane: A Manual for Nurses," Putnam, 1886. These three text 
books, from three widely separated English speaking localities, 
were voices of the time, calling for the training of attendants. So 
far as I know, each book was written without knowledge of the 
other on the part of the authors. 

At the meeting of the American Medico-Psychological Associa- 
tion, then the Association of Medical Superintendents, held at 
Lexington, Ky., 1886, I read a paper on " The Establishment of 
Training Schools in Asylums, and the Systematic Instruction of 
Attendants." 

Dr. George T. Tuttle, then first assistant at McLean, opened the 
discussion, giving an account of the school in that institution. 



FIRST TRAINING SCHOOL FOR ATTENDANTS 307 

The presentation of the subject by Dr. Tuttle and myself, and 
its immediate approval by the superintendents, have led me to 
consider this meeting as the birthplace of training schools in our 
hospitals for the insane, not only in this country, but elsewhere. 

It must, however, be confessed that training schools in institu- 
tions for the insane have not developed as have those of general 
hospitals. In 1909-10 there were employed in the New York State 
hospitals over 700 graduates, over 500 pupils in training and a 
little more than 2000 attendants. It is doubtful if 500 pupils in 
training can keep good the 700 graduates in institutions. The 
presence of 2000 attendants points to the failure of the institutions 
to afford instruction sufficient to attract those employees who 
demand instruction, and to bring to the service persons qualified 
for it. 

The reasons for failures are many. The increased size of the 
institutions ; the many duties of the superintendent, with enforced 
absence from close work and non-acquaintance with ward em- 
ployees ; the over-worked medical staff ; the large farms and scat- 
tered buildings; absence of concentration of clinical material, of 
medical w^ork and of nurse instruction ; and, more than any of 
these reasons, the effect of all combined has been to prevent the 
thorough organization of the schools. The schools too often are 
of secondary importance, or rather are crowded out of the first 
rank, in the mind or inclination of the superintendent and staff. 

A training school in a general hospital is a department so organ- 
ized as to stand apart from its general management in a measure. 
The superintendent of nurses is responsible for the school, has an 
authority over it and its individual members. She provides an 
efficient corps of nurses for the wards, and maintains the efificiency 
of the school. She is largely independent of control and the suc- 
cess of the school is due to her efforts. 

This cannot always be done in insane hospitals, but it can be 
approached and great power and responsibility can be placed in 
the hands of a fully capable superintendent. But, unless such a 
plan is worked out, and the schools are elevated to the first rank, 
the plan in the New York State hospitals will fail in part and the 
full success of the schools will not be assured. 

As a manager of the Mohansic State Hospital, I have written 
out a plan for that hospital too cumbersome to print. I have 



3o8 INSTITUTIONAL CARE OF THE INSANE 

endeavored to concentrate all the clinical work, making as a basis 
a building for the clinical director and the medical staff, with its 
laboratories and conveniences for research work. Round about is 
to be placed a reception building, a psychopathic building, the 
medical and surgical hospital, buildings for the infirm and all need- 
ing special care, a fully equipped building for " out-patients," 
where all ambulant cases of the hospital may be received, a build- 
ing or buildings to which different classes or groups or patients 
may be brought for prolonged and careful study, with buildings 
for employment and for scientific re-education. I would have a 
building for nurses providing quarters for as many as possible, 
where classes could be gathered and changed. This would be their 
headquarters, where the discipline, in the broadest sense of the 
word, would be carried out, every structural facility for instruc- 
tion would be provided, while clinical instruction and classified 
ward work would be joined to didactic instruction. Not only would 
a capable superintendent preside, but medical men and women 
should be relieved of other duties to give instruction. If this could 
be done, the training school would attract students and the school 
would take its place among the things of first importance. 

That something must be done, if our schools are to take a high 
rank, so as to compare favorably with schools in general hos- 
pitals, is evident. To reorganize our training schools, more than 
increased pay, nurses' homes, a club house or special privileges, are 
necessary. Provision must be made in the greatest degree possible 
for the clinical instruction of nurses in medicine and surgery, 
and in all branches of the application and art of nursing. If proper 
provision is made for that large class not requiring special hos- 
pital care, so that concentration of effort can be given to all requir- 
ing special care, it will, I believe, work such an interest in the medi- 
cal staff that they will make a demand that cannot be withstood for 
thoroughly trained nurses, and be satisfied with nothing less. In 
some such way the schools will come into their own, and then all 
things necessary will be added unto them. 

The time has come when, if we are to have real hospitals for the 
care of the insane, we must have trained nurses for the immediate 
personal care of each patient. To accomplish this, it is necessary, 
while caring for all classes of the insane, to build in true hospital 
construction for those needing special care, and bring such build- 



FIRST TRAINING SCHOOL FOR ATTENDANTS 309 

ings near enough together to become headquarters for the purely 
clinical and scientific administration, for the concentrated eflFort of 
the staff, thus making a training school necessary, something that 
must be in the front rank — and never neglected. Much of the 
benefit of the best clinical oversight must be lacking to epileptic 
and tuberculous patients placed in buildings two miles removed 
from the medical center, while the benefit to be obtained from 
them as a means of instruction in a training school is entirely lost. 
We must never forget that the loss entailed by the absence of 
structural arrangements is greater for the patients. They lose 
something which is theirs by right and which the state is bound to 
provide, for without such construction it is impossible for them 
to have the best clinical oversight and they are deprived of the 
services of a trained nurse. No patient, public or private, would 
go into a general hospital if a trained nurse was denied him. The 
public demands, and has built for it, hospitals structurally arranged 
for individual treatment, even to the last word. 



CHAPTER VIII 
PRIVATE CARE OF THE INSANE 



I. 

PRIVATE CARE OF THE INSANE. 

The care of the insane in famiUes or institutions at the personal 
expense of relatives, friends or guardians, in other words, the 
private care of insane patients, has existed from early days in the 
United States. 

In a discussion on the subject in one of the meetings of the Asso- 
ciation an interesting reminiscence was given by Dr. Isaac Ray of 
the condition and management of an institution which was in 
operation in New England in the latter part of the eighteenth cen- 
tury, and undoubtedly there were other similar establishments. 

An institution such as he described probably could not receive a 
license to-day from any Lunacy Commission, Board of Control or 
Board of Public Charities. As such places of detention were under 
no adequate supervision they could not fail to be under suspicion 
because insufficiently equipped and generally conducted by inex- 
perienced physicians and unfeeling attendants. 

There was also reason to fear that persons responsible for the 
support of insane relatives, especially if the latter were of the 
chronic and incurable class, might from motives of economy seek 
private treatment for them at a low cost. The experience of New 
York showed that when the statute requiring the insane be treated 
at Bloomingdale Hospital was amended to permit relatives and 
guardians to remove them to private care, the resultant abuse and 
neglect became such a crying evil as to require a restoration of the 
former statute which made treatment at Bloomingdale compulsory. 

It is not strange that such objectionable form of private care 
was early frowned upon by philanthropists and that in Pennsyl- 
vania and New York at least an appeal was made to the public for 
funds for the erection of general hospitals for the especial care not 
only of the sick and helpless but also of the insane. The Pennsyl- 
vania Hospital in Philadelphia was chartered for this purpose, as 
was also the New York Hospital. It is interesting to note that in 
the Pennsylvania Hospital patients were received from the begin- 
ning at the expense of their friends. The wife of Stephen Girard 
27 



314 * INSTITUTIONAL CARE OF THE INSANE 

was thus cared for in the Pennsylvania Hospital for many years, 
and eventually when she died was buried upon its grounds. Stephen 
Girard was then regarded the most wealthy merchant in the United 
States and yet his wife was cared for at a charitable institution at 
private expense. At the New York Hospital a separate building 
was erected for the care of private patients and pauper patients as 
well who were received under contract with superintendents of the 
poor of the different counties. Later when the Friends' Asylum, 
at Frankford, was erected it received private patients in a similar 
way ; the same was true of the Williamsburg Hospital in Virginia, 
and the South Carolina Hospital at Columbia. In Massachusetts, 
Connecticut, Rhode Island, Vermont and New Hampshire the 
original institutions like the Brattleboro Retreat, the McLean Hos- 
pital, the Butler Hospital, the New Hampshire Hospital, all cor- 
porate hospitals, were in effect at first private institutions ; they 
admitted patients at both public and private expense. Later when 
the Utica State Hospital was opened in 1843, patients were ad- 
mitted at the expense of counties and also of individuals, many 
being supported in the latter manner. 

This practice was extended to succeeding state institutions in 
New York as they were built and continued until 1894. The state 
hospitals of New Jersey, Pennsylvania, Maryland and Michigan, 
all received patients at private expense. Such patients generally 
received private apartments, a more varied diet, and greater priv- 
ileges than other patients. In return they paid a higher rate than 
was paid for the care of county, township or state patients. It is 
unquestionable that there was an unfairness in this arrangement, 
especially when it became necessary to ask for the removal of 
chronic patients to county hospitals in order to create room for 
acute cases. For such removals indigent patients were more often 
selected while those who paid more liberally for their treatment 
were sometimes retained at the state institutions, although of the 
chronic class. 

It is interesting to recall that considerable prejudice for many 
years existed against institutions owned and managed by individ- 
uals. In a paper presented to the Association in i860 by the late 
Edward Jarvis and published in the American Journal of Insanity 
for July of that year, an excellent description of private institutions 
in England was given. The accompanying declaration as to the 



PRIVATE CARE OF THE INSANE 315 

greater utility in the author's opinion of private institutions for 
certain classes of insane was received with more or less hostile 
criticism. In the discussion of the paper which followed, men 
eminent in the care of the insane like Kirkbride, Worthington, 
Tyler and McFarland criticised the establishment of such insti- 
tutions and contended that all patients of whatever class were 
more comfortable, better cared for and had better prospects of 
recovery in a state or corporate institution than in a private institu- 
tion. In i860 so far as is now known the only exclusively private 
institutions under proprietary control in the country were Sanford 
Hall on Long Island, and Brigham Hall at Canandaigua, N. Y. 
Sanford Hall had been in operation for nearly half a century and 
had given luxurious care to wealthy patients from Xew York, in 
a fine old mansion formerly occupied by a distinguished chancellor. 
Brigham Hall, named after Amariah Brigham, had been organized 
and opened in 1855 by Dr. George Cook, for many years as assist- 
ant at Utica, and Dr. John B. Chapin. Both institutions had 
excellent methods and although under private ownership were 
most useful and no reason existed to criticise their management. 

Although the general sentiment seemed to be that patients of 
every sort were better off in a public than a private institution, 
several who participated in the discussion, notably Dr. Isaac Ray, 
expressed the belief that certain classes of patients were more com- 
fortable in a private institution. He believed that there were many 
who no longer needed the discipline of a public institution and were 
much benefited by personal liberties which could be given to indi- 
viduals but might not be given to larger numbers. He confessed 
that he had recommended the removal of a woman from his insti- 
tution to a private one, so that she might be permitted to have a fire 
in her room at night and a candle burning at the same time. He 
believed that the great objection to a private institution was the 
matter of expense ; it was not possible to get as much comfort in a 
small, cheap private institution as in a large public one. Not- 
withstanding this dissent the well-nigh universal sentiment of the 
Association seemed to be unfavorable to private institutions. 

In spite of these objections, the time soon came when corporate 
and semi-private institutions like Bloomingdale, McLean, Brattle- 
boro, Hartford Retreat and the Butler Hospital, became private 
institutions because of the establishment of public institutions in 



3l6 INSTITUTIONAL CARE OF THE INSANE 

their various states for the care of indigent patients, who had 
formerly been sent to them under contract. This necessitated a re- 
arrangement of these institutions for the better accommodation of 
patients wholly at private expense, and they have been restricted to 
care of such patients for the past quarter of a century. 

The later policy also of many state institutions, as for example, 
in New York under the Lunacy Commission which discouraged the 
practice of receiving private patients, had much to do with the 
establishment of small private institutions in several states after 
the adoption of state care. In states where accommodation for 
patients under the care of the state was lacking it was manifestly 
unjust to fill up the hospitals with paying patients to the exclusion 
of those who were in poorhouses or county receptacles. There has 
accordingly grown up in New York a large number of private 
institutions of varying size. In Connecticut, on the edge of New 
York, several large institutions for the care of private patients have 
been developed for a similar reason. 

Another factor which has unquestionably influenced the erection 
and development of private institutions has been the great increase 
of wealth in the United States. Patients were formerly placed in 
public institutions at private expense as a measure of economy, but 
the growth of fortunes and a feeling which exists among many 
persons that there is less stigma attached to private institutions 
because of less publicity among its inmates, often leads wealthy 
families to place their dependent friends under private care. Many 
also have a feeling that the medical care and nursing received at 
private institutions are better or at least more individualized than 
in large institutions, crowded with patients of dififerent classes. 

The care of private patients in this country is now assumed by 
three different classes of institutions : 

1. Institutions under the charge of incorporated hospitals asso- 
ciated as departments with general hospitals for the care of general 
diseases, such as the McLean Hospital, the Bloomingdale Hospital 
and the Pennsylvania Hospital. 

2. Others like the Butler Hospital, the Sheppard and Enoch Pratt 
Hospital, the Brattleboro Retreat, and the Hartford Retreat, are 
incorporated hospitals, arranged exclusively for the care of patients 
of a private class. All of them have funds at their disposal which 
may be used for the benefit of persons in straitened circumstances, 



PRIVATE CARE OF THE INSANE 317 

but patients are not treated without charge unless arrangements 
can be made for the use of such funds. Many undoubtedly are 
treated at less than actual cost, but the majority of patients pay for 
their care and treatment. 

3. A third class of institutions is exclusively under private 
ownership and control, although often incorporated. These insti- 
tutions are intended to produce an income for share-holders or 
proprietors, and are not in any sense to be considered charities. Of 
these institutions there are many of excellent standing in the 
wealthier states like New York, Michigan, Wisconsin, Illinois, 
California and other states. There are also a number of institu- 
tions which have a certain resemblance to these under the charge 
of one or more of the religious orders of the Roman Catholic 
Church, such as the Mount Hope Retreat near Baltimore, St. Vin- 
cent's Institution near New York, Providence Retreat near Buffalo, 
St. Joseph's Retreat in Detroit and St. Vincent's Hospital at St. 
Louis. Some of these have arrangements with the municipalities 
in which they are situated or adjoining them, for the care of 
patients of the dependent class, but all of them have facilities for 
the care of private patients and receive an income from it, which 
has enabled them to spend considerable sums of money in the 
development of their institutions. Another similar class of private 
institutions consists of those which are maintained by physicians 
as a means of livelihood. Many of them originally started in 
private houses and have developed into well-built, convenient, well- 
equipped and acceptable and comfortable places for the care of the 
insane. 

An effort has been made to get a list of all these institutions with 
a description of their buildings and facilities. It is a matter of 
regret to the committee that it has been unsuccessful in getting a 
complete list of the latter institutions. 



CHAPTER IX 

COMMITMENT AND DISCHARGE 

VOLUNTARY ADMISSIONS 

CRIMINAL INSANE 



GROWTH OF THE LAW OF INSANITY. 

The right to deprive an insane person of his Hberty existed in 
England under the common law, and was transferred bodily to 
America when the colonies were established. The provision, how- 
ever, was originally intended to cover only cases of emergency, 
where immediate restraint was required and where any delay 
would be dangerous ; hence an insane person, dangerous to himself 
or others, could be arrested by any one as a matter of public pro- 
tection and temporarily detained in any suitable place, provided it 
could be done in a humane manner, until such time as some per- 
manent disposition could be made of him. The authority in this 
case was limited to the actual necessities of the moment and did not 
in any way confer the right to keep him in confinement after his 
paroxysm of excitement had passed. As soon as possible accord- 
ingly, after such arrest, judicial proceedings must be instituted to 
determine the propriety of such detention and to free the person 
responsible for it from liability to damages for false imprisonment. 

In England insane persons might not only be confined but even 
subjected to harsh treatment if such measures were regarded as 
necessary for their cure. In fact, the statutes relating to lunacy 
formally declared that nothing in them should be taken to abridge 
the power of the Court of Chancery to deal with them, or to pre- 
vent any friend or relative from acting as he deemed necessary in 
the case of persons of unsound mind. It was regarded as justifiable 
" to confine, bind and beat " them in such manner as might be 
requisite under the existing circumstances. It was further held 
that any man was justified in making an assault to restrain the 
fury of a lunatic and to prevent mischief, while a similar justifica- 
tion was accorded to physicians in attendance on insane persons. 

Building upon the common law in England, it was ruled early 
in the century in New Hampshire that if it was dangerous for an 
insane person to be at liberty, any one might confine him for a 
reasonable time without warrant, until proper proceedings could 
be had for the appointment of a guardian. In Massachusetts, 
about the year 1845, Chief Justice Shaw uttered the opinion that 



322 INSTITUTIONAL CARE OF THE INSANE 

the right to restrain insane persons of their Hberty is found in 
the law of humanity, which makes it necessary to confine those who 
would be dangerous to themselves or to others. 

Legal grounds for the commitment of a patient to an institution 
for the insane were declared to be : 

1. That his disease requires restraint and seclusion. 

2. That he is dangerous to himself or to others by reason of 
suicidal or homicidal tendencies or by liability to acts of personal 
violence during unrestricted intercourse with his fellow men. 
Proof of such dangerous tendency must be presented and not 
merely inferred from the fact that he is insane. 

3. That he has dangerous and irresistible tendencies to destroy 
property on a large scale, as by arson, and is a menace to the 
community. 

4. That he is liable to wander about and become lost and to suffer 
from lack of food or shelter and cannot be properly supervised and 
controlled at home. 

5. And that his disease requires for its proper treatment seclu- 
sion, rest and quiet, which can only be afiforded in an institution 
for the insane. 

Under the ruling of Chief Justice Shaw in 1845, it was not 
regarded essential that the patient should have committed actual 
violence ; repeated and frequent recurrence of insane acts without 
motive sufficient to actuate persons of ordinary senses were con- 
sidered sufficient evidence of aberration of mind and such aberra- 
tions authorized the restraint of the person subject thereto, 
although he might not have committed any act of violence. In other 
words the principle of law was laid down that acts of violence 
were regarded simply as evidence of disease and that if other evi- 
dences of mental disease existed, the insanity of the person was 
sufficiently established and it was not essential that acts of violence 
should be a prerequisite to admission to an institution. 

The legal principle, however, continued to hold that an insane 
person could be confined in a hospital only for medical treatment ; 
that his confinement was justified only by necessity, and that the 
right to confine him could be exercised only as long as the necessity 
for it continued. In short, an insane man could not be deprived of 
his liberty unless such restraint was necessary or beneficial, and a 
commission or guardian or the superintendent of the poor could 



GROWTH OF THE LAW OF INSANITY 323 

only confine him when authorized to do so by the court. The right 
to confine a patient was regarded as distinct from the duty to pro- 
tect and maintain him and did not necessarily grow out of the 
fact of his insanity. 

In the colonies, however, a modification of the English practice 
grew out of the fact that there were few and often no proper insti- 
tutions to which insane persons could be sent. This was espe- 
cially the case with insane paupers, who were sent to institutions 
without certificates of insanity by the superintendents of the 
poor, because the latter, being charged with their care and support, 
regarded it a matter of indifference whether they were in alms- 
houses or in special institutions for the care of the insane. Their 
right was not questioned because it was not for the interest of any 
one to question the legality of the practice. There was no written 
law for the practice until many years after. 

In New York the act creating the State Lunatic Asylum at Utica 
was the first definite step towards securing the proper commitment 
of patients to asylums, and even after its enactment it was still cus- 
tomary to send pauper patients to institutions without certificates of 
insanity or any formality beyond the simple order of the superin- 
tendents of the poor, which in fact only guaranteed the payment 
of necessary expenses. The same practice existed for a long time 
in some of the Western States ; in fact, it was not until after 1870 
that the presentation of certificates of insanity from physicians of 
recognized responsibility was regarded as essential to the commit- 
ment of patients throughout the United States. For a long time 
patients under guardianship were committed by their friends and 
relatives without any recognition of the fact by a court of record. 
Even now certain states, e. g., Rhode Island, Maryland, Connecti- 
cut, New Hampshire and others, receive private patients in state 
institutions for the insane without any formality other than the 
request of the guardian and the certificates of two physicians of 
recognized responsibility. 

It is to be regretted that no connected account can be given of 
lunacy legislation in the different states, because in the majority of 
them legislation did not spring up spontaneously, but developed 
gradually out of the condition of the country, nor was it derived, 
as in England, from an extension of the provisions of the common 
law. In nearly every state the earliest statute enacted was brought 



324 INSTITUTIONAL CARE OF THE INSANE 

bodily from one of the older states. It is deemed desirable to trace 
the evolution of the present laws of commitment in one or more 
of the states and to note the gradual strengthening of the safe- 
guards thrown about the irresponsible insane in all proceedings 
instituted to deprive them of their liberty. It is, therefore, thought 
proper to give a sketch as far as practicable of the law as it 
developed in the State of New York, because New York has widely 
influenced legislation throughout the country. 

In New York as a colony the English common law was adopted 
as it was applicable to the condition of the insane, by which law 
idiocy or lunacy was a civil disqualification. The law which pre- 
vailed in England had equal force in her colonies wherever the 
legal status of a person became a question for judicial determina- 
tion. There seems no reason, therefore, why the colonial laws of 
New York should contain any special legislation relating to insane 
persons. The first provision, according to Ordronaux, is to be 
found in Section 5, Chapter 47, Laws of 1787, Statutes of New 
York, and is entitled " An Act to Reduce the Laws Concerning 
Wills into a Statute." This act, which declares idiots and persons 
" of unsane memory " incapable of devising lands, follows the old 
English act of Edward II. Concerning it Ordronaux remarks : 

" Thus, in the case of idiots no allusion is made to them as possi- 
ble householders having dependent families, or again, to the pos- 
sibility of their recovery from such an infirmity ; while in the case 
of lunatics both of these conditions are mentioned and provided 
for. The statute thus regards idiocy as an incurable infirmity a 
nativitate, while in the case of the lunatic it extends its protection 
over him and his estate only duni fuit non compos mentis." 

The next statute, from Chapter 31, Laws of 1788, is a re-enact- 
ment of Statute 17, Chapter 5, of George II, entitled "An Act 
for Apprehending and Punishing Disorderly Persons," Section 6. 
It reads as follows : 

Whereas, There are sometimes persons who by lunacy or otherwise 
are furiously mad, or are so far disordered in their senses that they 
may be dangerous to be permitted to go abroad ; therefore, 

Be it enacted. That it shall and may be lawful for any two or more justices 
of the peace to cause such person to be apprehended and kept safely locked 
up in some secure place, and, if such justices shall find it necessary, to be 
there chained, if the last place of legal settlement be in such city, or in any 
town within such county; and if the last legal place of settlement of such 



GROWTH OF THE LAW OF INSANITY 325 

person shall not be in such city or county then such person shall be sent 
to the place of his or her last settlement, etc. 

No further legislation for the insane appears to have been 
enacted during the succeeding 12 years. In 1800, however, a case 
arose requiring the intervention of the Legislature in behalf of an 
insane person convicted of murder, and under sentence of death, 
which gives an example of the difficulties which were encountered 
in dealing with the insane in the absence of proper legislation. 
The Governor not being at that time empowered to grant pardons 
in such cases, and there being no insane asylums in the state within 
which the convict could be confined, the Legislature was the only 
tribunal to which an appeal could be taken for clemency. An act 
was accordingly passed to cover the case, which is to be found in 
Chapter 3, Laws of 1800, as " An Act to Pardon John Pastano for 
Murder/' 

Whereas, John Pastano, at a Court of Oyer and Terminer, held in and 
for the City and County of New York, on the 19th day of November, 1799, 
was convicted of the murder of Alary Ann De Castro, and sentenced to 
be executed accordingly, which execution has been suspended by His 
Excellency, the Governor, until the 27th day of February. And, 

Whereas, It appears satisfactorily to the Legislature, from the testimony 
submitted and discovered since the trial of the said John Pastano, that at 
the time of the commission of the act aforesaid he was insane, and is there- 
fore a proper object of mercy ; therefore, 

Be it enacted, etc.. That the said John Pastano be and he is hereby fully 
and absolutely pardoned and discharged from the felony and conviction 
aforesaid, and all execution and forfeiture thereon. Provided, never- 
theless, that the said John Pastano shall continue confined in prison until 
the assurance which has been made of security's being given that he shall 
be immediately sent to Madeira, where his connexions reside, shall be 
complied with to the satisfaction of the Mayor or Recorder of the City 
of New York. 

It will be remembered that under the act of 1787 idiots and 
insane persons were deprived of the power to devise real estate. 
By the act of 1801 they were also deprived of the power to dispose 
of personal estates as well. 

Chapter 30, Laws of 1801, is very itnportant because it gives 
to the Chancellor the power to care and provide for the safekeep- 
ing of idiots and lunatics and of their real and personal estates, as 
well as to provide for their maintenance and that of their families 
by using the money on hand and, if necessary, to sell real estate for 



326 INSTITUTIONAL CARE OF THE INSANE 

that purpose. It also provides that the estate of any lunatic in 
case of his recovery shall be restored to him and in case of his 
death shall descend to his heirs. 

The first law for the support of a hospital to take care of insane 
people was passed in 1806 and was intended as an appropriation to 
the New York Hospital. It was entitled " An Act for the Better 
and More Permanent Support of a Hospital in the City of New 
York," and its purposes were as follows: 

Whereas, It has become necessary on account of the increasing number 
of patients in the hospital in the City of New York to enlarge the same 
by erecting additions thereto for the more convenient accommodation of 
the sick and disabled, and particularly to provide suitable apartments for 
the maniacs, adapted to the various forms and degrees of insanity ; and 

Whereas, The said hospital is an institution of great public utility 
and humanity, as well as the general interests of the state require that 
fit and adequate provision should be made for the support of such an 
infirmary for sick and insane persons ; therefore, the better to enable the 
governor of the said hospital, by means of a permanent fund, to maintain 
and improve the said hospital. 

Be it enacted, etc., That the Treasurer of this state shall every year 
hereafter, until the year one thousand eight hundred and fifty-seven, upon 
the warrant of the Comptroller, pay to the Treasurer of the society of 
the hospital, in the City of New York, in America, for the use of the 
said corporation, in quarterly-yearly payments, out of any moneys in the 
treasury of this state not otherwise appropriated, the annual sum of 
$12,500, the first quarterly payment to be made on the first day of May, 
next, which said annual sum of $12,500 shall become chargeable upon 
the duties on sales at public auction in the said City of New York. 

In an act of 1809, Chapter 90, it was provided that the overseers 
of the poor of any city or town, with the consent of the common 
council or of two justices of the peace, shall make a contract with 
the governors of the New York Hospital for the maintenance and 
care of all persons who become lunatics and the payment of such 
sums of money as may be agreed upon to the governors of the 
hospital by the overseers of the poor and their successors in 
office. It will be noticed that no provision is made here for the legal 
commitment of these patients to the hospital. Prior to their becom- 
ing insane they were charges upon the town, or city, or county as 
paupers and the contract with the hospital in no way changed their 
status in respect to the overseers of the poor. It was made the 
duty of the overseers of the poor to keep an account of the amount 
expended for the relief of the insane and it was further provided 



GROWTH OF THE LAW OF INSANITY' 327 

that their transfer to the hospital should not in any way change 
their settlement, but that their legal settlement should remain the 
same as if they had not been sent to the hospital. Ordronaux says 
" this is the first legislative enactment in this state making pro- 
vision for the pauper insane as a distinct class entitled to care 
and medical treatment in a special hospital." 

It is interesting to notice that in a number of states a similar 
right was conferred upon the superintendents of the poor to send 
insane paupers to a hospital for the insane without going through 
the formality of a legal commitment. It is also evident that in 
other states the possession of such right was inferred, though not 
conferred by statute, a fact which subsequently led to difficulty 
and in one instance to a suit against the superintendent of a hos- 
pital for receiving an insane pauper without her being accom- 
panied by proper certificates of insanity.^ In Chapter 294, Laws of 
1827, a provision is found that no lunatic shall be confined in any 
prison, jail or house of correction, nor shall be confined in the same 
room with any person charged with or convicted of crime, but 
shall be sent to the asylum in New York (that is, to the New 
York Hospital) or to the county poorhouse or almshouse or 
other place provided for the reception of lunatics by the county 
superintendents. 

It is also interesting to notice in the same act a provision to the 
effect that it shall be the duty of the parents or relatives of any 
lunatic to support him in the asylum or elsewhere if they are able 
to do so, but the curious provision is added that no relative shall 
be liable for such support if he, at his own cost, provide a suitable 
place for the confinement of such lunatic and shall confine and 
maintain him in the manner approved by the overseer of the poor 
of the town. If this be done, it is not lawful to remove such lunatic 
from the custody of his relatives. It is gratifying to notice that 
this provision was not re-enacted when the revised statutes were 
first compiled, since it led, very naturally, to the confinement of 
insane people in pens and cages, or in unsuitable, unhealthy quar- 
ters in private houses or elsewhere as a measure of economy, and 
unquestionably the privilege was often abused. 

In Chapter 82, Laws of 1836, an act was passed to authorize 
the establishment of the State Lunatic Asylum. The law which 
provided for the organization of the same State Lunatic Asylum 

* See page 333. 



328 IXSTITUTIONAL CARE OF THE INSANE 

passed in 1842 contained many clear provisions for the care of 
the insane. 

According to this act, the overseers of the poor of towns 
(in counties where the distinction between the town and county 
poor existed), the superintendents of the poor of counties, jus- 
tices of the peace, and the first judge of the county, or in his 
absence, any county judge of the degree of counsellor of the 
Supreme Court might send patients to the asylum. But the laws 
did not intend that each of these authorities should send patients 
of every class. The overseers and superintendents of the poor 
were to send the paupers, and also those who were committed 
to their charge by justices of the peace as dangerous. The 
first judge was to send those that were indigent, but not paupers, 
and the justices of the peace to commit to the care of the over- 
seers or superintendents of the poor for transmission to the asy- 
lum, " any person so far disordered in his senses as to endanger 
his own person or the person and property of others, if permitted to 
go at large." Judges of the county were to commit those who 
became insane while in confinement under criminal charges, and 
those acquitted of crime on the ground of insanity. The superin- 
tendents of the poor of counties had the right to send to the asylum, 
provided it was not full, any insane person in their charge, without 
instituting any proceedings to prove his insanity, provided the 
insanity began previous to the passage of the act to organize the 
asylum, under date of April 7, 1842. Thus the poor were sent to 
the hospitals without certificates of insanity from physicians or 
any recognition on the part of the judge of probate or the county 
judge of the need of an inquiry into the propriety of their commit- 
ment. It further provided that indigent patients should be received 
on the certificates of two physicians as to insanity and a commit- 
ment from the judge of probate of the county, the idea seeming to 
be that the certificates were essential to determine the question of 
insanity, while the committing order from the judge of probate 
was to secure free care to an indigent person unable to secure it at 
his own expense, and to support his family during his attack of 
insanity. There is reason to think that the provision of law requir- 
ing commitment at the hands of a judge of probate was designed 
especially to secure that justice was done both to the county and to 
the individual in the matter of treatment at the expense of the 
county. 



GROWTH OF THE LAW OF INSANITY 329 

No special change was made in the laws providing for the com- 
mitment of patients until 1874, when the law was revised and a 
commissioner in lunacy was appointed to supervise institutions for 
the insane in place of the Board of State Charities, to which this 
duty had formerly been assigned. The Commissioner in Lunacy, 
Dr. John Ordronaux, was appointed to revise and consolidate the 
statutes of the state relating to the care and custody of the insane. 
This revision was distinctly an improvement on former acts, 
because it provided that no person should be confined or com- 
mitted as a patient to any asylum except upon the certificates of two 
physicians under oath and that no person should be held in con- 
finement more than five days, unless within that time the certificates 
were approved by the judge or justice of a court of record of the 
county or district in which the insane person resided, also that the 
judge or justice might institute inquiry and take proofs, and even, 
at his discretion, call a jury to determine the question of insanity. 
The law of 1874 continued in force until 1889, when the statute 
providing for the care, custody and inspection of the institutions 
for the insane was amended so as to provide three commissioners 
in lunacy instead of one. These commissioners in lunacy were to 
consist of a physician, a lawyer, and a business man and were to 
have supervision of the medical and personal care of patients, as 
well as of their proper commitment to institutions for the insane. 
They were also charged with the duty of providing for all insane 
persons in the state institutions, thus doing away with county 
institutions, which had been the source of many abuses. After a 
few years it became necessary, in the opinion of the commission, 
to ask for increased authority, which was conferred, and the 
Lunacy Commission assumed many duties formerly discharged by 
the managers of institutions. Up to this time the latter had con- 
trol of buildings and of the appropriations for the maintenance of 
patients, the appointment of superintendents and other officers, the 
supervision of all accounts, the purchase of supplies, and the gen- 
eral management of all institutions. Since that date these varied 
administrative duties have been discharged by the Lunacy Com- 
mission. Within the past year ( 1912) the name of the commission 
was changed to that of the State Hospital Commission and cer- 
tain duties and responsibilities formerly devolving upon it were 
transferred to the boards of managers. The Lunacy Commission 
28 



330 IXSTITUTIONAL CARE OF THE INSANE 

has reliiKjuished in some degree its power to purchase supplies, 
and has placed this matter in the hands of a committee composed 
of the superintendents and officers of institutions. 

It is not to be wondered at that the duties assumed by the Lunacy 
Commission, in its effort to centralize authority, met with more or 
less opposition on the part of the various institutions. The excel- 
lent results obtained are largely due to the fact that the New 
York law contemplated an expert control of institutions. The 
medical commissioner in lunacy was required to have had ten 
years' experience in the care of the insane and was made president 
of the commission. The lawyer and the business man were also 
expected to have special fitness. In the board of control estab- 
lished in the West, an effort has been made to do away with the 
preponderance of medical authority and to establish boards of 
control upon a business, rather than a professional, basis. This 
will be more clearly understood when we come to speak of boards 
of control in greater detail. 

Under recent legislation in New York also the predominant 
position of the medical member of the Lunacy or State Hospital 
Commission has been abolished and all three members are placed 
upon an equal footing. 



II. 

COMMITMENT OF THE INSANE. 

It is interesting to note the development of the present law in 
reference to the commitment of the insane which grew out of the 
common law in England. As has been stated in another connec- 
tion, the custody of insane persons was assumed to be part of the 
police powers of the state, which were not to be exercised unless 
the insane person became dangerous to himself or others by reason 
of violent and irresponsible acts. In the exercise of these powers 
no thought was taken of the possibility of curing him. Custody 
and care were regarded as essential, not to the care of the insane 
man himself, but to the welfare and safety of the community, 
which must be protected from his violent homicidal tendencies, his 
inclination to arson or his impulse to commit other depredations 
upon the property rights of others in consequence of his irresponsi- 
bility. Hence the right to confine and restrain insane people was 
assumed under the police powers of the state, but could only be 
exercised while the person was violent or until it was practicable 
to make some legal disposition of him. 

Under the English law, anybody could arrest a supposedly 
insane person, provided it was done in a humane manner, and con- 
fine him until his condition was inquired into. It was also proper 
to exercise any degree of violence which might be required to con- 
trol his irresponsible fury. It was, however, the theory of law 
that the right to arrest and confine during inquiry did not give the 
right to continue to confine indefinitely, but only until such time as 
the patient's mental condition could be determined by proper judi- 
cial proceedings. 

This brings us to the consideration of another fact which is 
sometimes overlooked. Although a person is clearly insane, his 
lunacy does not give even his relatives the right to restrain him 
beyond the period of an emergency until the necessity for his 
restraint and confinement is determined by a court. No one, in 
fact, has the right to restrain any insane person more than tem- 
porarily until he has authority from a court of competent juris- 
diction to do so. 



332 INSTITUTIONAL CARE OF THE INSANE 

In England paupers as well as dissolute and irresponsible per- 
sons were under the custody of the vestries of the Established 
Church and were cared for as best suited the requirements of their 
several conditions. A similar provision was extended to this 
country wherever the Established Church existed, as in Virginia 
and Maryland. In New England, w^here there was no Established 
Church, nor any board of vestrymen or persons charged by eccle- 
siastical law with the care of the helpless insane, similar duties and 
powers were conferred originally upon the selectmen of the town 
and later upon the overseers of the poor. It is of interest to note 
also that when, after the Revolution, the church in Virginia was 
disestablished, it became necessary to pass an act to establish over- 
seers of the poor in place of vestries for the care of the indigent. 
It is apparent that in dealing with the insane in America it was 
necessary to create a new body of officials in harmony w-ith existing 
American institutions. When jurisdiction was given to the over- 
seers of the poor to care for the pauper insane, they generally 
received authority by law to place these patients where they could 
be cared for most conveniently, as for example in New York, where 
special authority was given to the overseers of the poor in different 
counties to make contracts with the New York Hospital for their 
care in that hospital. 

Later, little or no consideration was given to the fact that the 
insanity of these paupers had not been legally determined, ihey 
were cared for under a contract in the New York Hospital in the 
same manner that they would have been maintained by the super- 
intendents of the poor in their own county almshouses, it being 
regarded as entirely a question of support and not of legal commit- 
ment. This practice was followed in various other states, prob- 
ably on the initiative of New York. Eor many years the super- 
intendents of the ])oor also exercised the right to send patients to 
the state hospital over their own signatures without any adjudica- 
tion of the fact of insanity. In fact, up to the present time traces of 
this method of sending patients to institutions still exist, lender 
the law of Georgia the certificate of the " ordinary " of the county 
wdiere an insane negro resides certifying to his condition, mental 
and ])ecuniary, is sufficient to secure his admission to the hospital. 
In North Carolina and Connecticut a ])arent or guardian of an 
insane child seems to have the right to place him in a hospital for 



COMMITMENT OF THE IXSAXE 333 

the insane upon the certificate of physicians, without any legal 
adjudication of the question of insanity. This course was pursued 
in the majority of states for many years and has but recently been 
discontinued. 

Under a strict view of the law no one has any right by virtue of 
marriage or blood relationship to commit any person to an institu- 
tion for the insane, nor does the fact of guardianship or the pre- 
sentation of certificates from competent physicians establishing 
insanity give any right to confine an insane person in such an insti- 
tution. In the eyes of the law as at present interpreted, no person 
can be confined in an institution except by an order of a court of 
competent jurisdiction. 

Ordronaux says that under the common law an insane person 
might be confined anywhere as a person dangerous to be at large : 
he might be put in a jail, or house, or pen, or any other place of con- 
finement where he could be kept in safety. 

The original law of New York provided that " Xo lunatic may 
be confined in any prison, jail or house of correction or confined in 
the same room with any person charged with or convicted of crime, 
but he shall be sent to the asylum in New York or to the county 
poorhouse or almshouse or other place provided for the reception 
of lunatics by the county superintendent." Subsequently it was 
provided that no parent or relative of any insane person thus con- 
fined shall be liable for his support if he shall provide a suitable 
place for his confinement, and shall confine and maintain him in 
such manner as shall be approved by the overseers of the poor of 
the town and in such case it shall not be lawful to remove him from 
the custody of his relatives who shall thus provide for him. This 
proviso put a premium upon bad treatment, neglect and abuse. Its 
effect upon the care of the insane was so unfortunate that it was 
soon repealed and the care of the insane at home was not permitted. 

Reference has been made to the fact that insane paupers were 
formerly sent to institutions for the insane over the signatures of 
the superintendents of the poor without any legal commitment or 
certificates of physicians as to insanity. In Michigan, in the year 
1877, a pauper patient was sent to the Michigan Asylum at Kala- 
mazoo, under an order of this kind from the superintendents of the 
poor, without any certificate of insanity. Subsequently she brought 
a suit against the superintendent of the institution alleging that she 



334 INSTITUTIONAL CARE OF THE INSANE 

had been detained without proper authority, and secured a verdict 
of $6000 damages. The case was appealed to a hic^her court and 
a new trial ordered to determine whether the superintendent of the 
institution had acted in good faith in receiving her. At the new 
trial the case was taken from the jury and a verdict ordered on 
behalf of the defendant, on the ground that his action had been in 
perfect good faith and that the continued insanity of the patient 
had rendered it impossible for him, after allowing her to be placed 
in his custody, to set her at liberty. The judge in taking this action 
declared that the good faith of the superintendent of the institu- 
tion in retaining the patient must constantly be recognized, no mat- 
ter what legal authority had been given in the first place, or what 
certificates had been brought. It was his duty to decide the ques- 
tion of insanity and necessity of continued confinement of each 
patient under his care, and if, in his opinion, the necessity for 
confinement still continued, and he honestly and conscientiously 
believed that the patient should not be set at liberty, his good faith 
in retaining such a patient should be a protection in the exercise of 
his authority as superintendent. 

In this connection the question arises as to what degree of 
danger there should be in the condition of the insane person to 
justify his continued confinement in an institution. As a matter of 
fact, many, perhaps the majority of insane people, do not continue 
in a state in which it is necessarily dangerous for them to be at 
large, so that the original necessity which demanded their admis- 
sion to the asylum, hospital or sanitarium does not always continue. 
The inquiry then presents itself. How dangerous shall a person be? 
Or, as (3rdronaux expresses it, How dangerous to the present and 
future welfare of the individual is his insanity? The question of 
cure cannot be disregarded in the answer as well as the fact that 
incurability may be as great a calamity to the patients as any danger 
from his irresponsible actions to the community. In deciding upon 
the necessity for confinement, the decision of the question should 
rest not only upon the dangerous character of the jiatient's conduct 
to others, but also upon the danger of the disease to the patient 
himself. The view has been expressed by Baron Pollock that the 
object of the English lunacy acts is not so much to place lunatics in 
confinement as to restore to a healthy state of mind such as are 
curable, and to afford comfort and protection to the rest. The 



COMMITMENT OF THE INSANE 335 

difficulty of ascertaining whether an insane patient be dangerous or 
not is great, and often can only be determined after close observa- 
tion extending over a long period of time. 

As a result of the " personal liberty bills " which were passed 
in a number of states following the agitation originated by Mrs. 
Packard, in Illinois, a provision of law^ for the jury trial of insane 
cases in open court after their arrest by the sheriff and prosecution 
by the district attorney was not uncommon. For many years in 
Illinois the necessity of a jury trial to determine insanity was pre- 
scribed by law and no patient was committed without it. At pres- 
ent the matter of a jury is left to the discretion of the judge unless 
a jury trial is demanded. In several other states a similar system 
still exists and patients cannot be committed until the question of 
insanity has been passed upon by a jury. In some states the pro- 
ceeding is optional. If a jury is demanded, the fact of insanity 
must be determined by a jury. The value of a jury trial to deter- 
mine the existence of insanity seems to have been much over- 
estimated. Where it has been insisted upon it has often resulted in 
error and has constituted no safeguard to the liberty of the individ- 
ual or the safety of the community. Under the English law a trial 
by jury was not regarded essential nor was it in the older states ; it 
being found practicable for the judge to act with equal or greater 
wisdom, with less delay and without interfering unduly with the 
liberty of the individual. 

Many persons have contended that unless the insane are com- 
mitted by jury trial they are restrained of their liberty " with- 
out due process of law," but it has been clearly pointed out by 
Ordronaux and others that " due process of law " means the law 
of the land, so that any law which is properly placed upon the 
statutes must be considered " due process of law." 

In examining the laws of commitment and the procedures under 
them, I find that in five states of the Union, viz., Colorado, Ken- 
tucky, Mississippi, Texas and Wyoming, it is imperative that the 
commitment of patients shall be after a verdict by a jury. 

In four others, viz., Alabama, Massachusetts, Missouri and Wis- 
consin, a jury is not imperative, but may be impaneled at the dis- 
cretion of the court. In five states, viz., Georgia, Kansas, Mary- 
land, Michigan and Washington, a jury must be impaneled w^hen 
demanded by the patient or his counsel. 



336 IXSTITUTIONAL CARE OF THE INSANE 

In one state, Illinois, a jury or a commission must determine the 
question of insanity and the presence of the insane person in court 
is at the discretion of the judge. 

In several states, when an appeal is taken from the decision of 
the judge of probate that a person is insane, the appeal must be 
tried before a jury. 

In ten states, viz., Iowa, Kansas, Louisiana, Minnesota, Ne- 
braska, North Dakota, Oklahoma, Pennsylvania, South Dakota and 
Virginia, the question of insanity is determined by a commission 
— usually a county commission. 

In 24 states, viz., Arizona, Arkansas, California, Connecticut, 
Delaware, District of Columbia, Florida, Idaho, Indiana, Maine, 
Nevada, New Hampshire, New Jersey, New Mexico, New York, 
North Carolina, Ohio, Oregon, Rhode Island, South Carolina, 
Tennessee, Utah, \"ermont and West Virginia, no mention of a 
jury is made in the law. In the majority of these states the old- 
fashioned form of admitting patients, clearly traceable to the orig- 
inal act organizing the Utica State Hospital or the scheme of the 
law prepared about 1850 by Dr. Isaac Ray, may be discovered. 

In some of the states, instead of certificates from any physician, 
or " any reputable physician " as the phrase used to be, special 
qualifications are insisted upon, which must be certified to by the 
judge of a court of record. 

In California the law provides that there must be at least two 
medical examiners in each county. In New York, Massachusetts, 
Michigan and Ohio, the examining physician must possess special 
qualifications. It is interesting to notice that while at first patients 
were admitted very loosely, upon certificates of physicians, and 
little pains were taken to establish the competency of those who 
made the certificates, at the present time the tendency seems to be 
strong towards securing expert testimony as to the insanity of a 
person prior to his admission to a hospital. It is rather interesting 
to notice that wherever boards of control exist or central executive 
boards like a lunacy commission, now a hosj^ital commission, in 
New York, a board of insanity in Massachusetts, a board of admin- 
istration in Illinois, there is a marked tendency to control the certifi- 
cation of patients. In some states the appointment of commis- 
sioners of insanity in each county, consisting of the county judge, 
a physician and a lawyer, is deemed preferable ; in other states com- 



COMMITMENT OF THE INSANE 337 

missioners of insanity in those counties where institutions for the 
insane exist are created to pass upon the question of the proper 
admission of patients and to give a degree of confidence to the 
pubhc. 

It is of interest to observe, however, that in connection with 
greater care as to the admission and commitment of patients, there 
is an increasing tendency to open the doors of institutions to volun- 
tary patients. It seems ahnost an anomaly to legalize the admission 
of a voluntary patient by his own written application for admission 
to be treated for a disease, the chief characteristic of which is a 
condition of irresponsibility. 



III. 

CONDITIONS OF DISCHARGE. 

A brief mention of the conditions of the discharge of patients 
from the hospital seems necessary; also the matter of the dis- 
charge of patients on parole or on probation. 

Arizona. — A provision of law exists for the discharge of patients 
on parole, the only proviso being that no patient guilty of suicidal 
or homicidal tendencies shall be paroled. Recovered patients are 
to be discharged upon recovery. 

Alabama. — The period of parole or of probationary discharge 
may be extended to a period of six months. Recovered patients 
can be discharged upon recovery. 

Arkansas. — There is no provision for parole. Recovered patients 
are discharged and incurable patients also are discharged, if it 
becomes necessary to find room for other patients. 

California. — The superintendent under such restrictions and 
agreements as he may deem necessary may permit a patient to leave 
the institution for a period not to exceed six months. Any person 
held in confinement under an order of the court may, upon satis- 
factory proof that he is restored to reason, receive an order for his 
discharge. 

Colorado. — The superintendent may grant a probationary dis- 
charge. If a patient is restored to reason he must be discharged 
and the superintendent must notify the judge of the county court. 
If such discharge is not granted any applicant may present a 
petition to the county court, whose duty it becomes to appoint two 
physicians to make further inquiry. If the patient is found to be 
restored to reason he must be discharged. 

Delaware. — The superintendent must discharge, with the consent 
of the trustees, a patient who has recovered. He is also empowered 
to return all indigent and incurable insane to the almshouse of the 
county of their residence. 

District of Columbia. — Authority to discharge a recovered 
patient is vested in the superintendent. He must file a sworn state- 
ment with the clerk of the Suj)rcme Court of the District of Colum- 
bia that the patient is restored and this statement is suflficient to 



CONDITION'S OF DISCHARGE 339 

authorize the court to restore him to his former leg:al status as a 
person of sound mind. 

Florida. — Has no legal provision for the discharge or parole of 
patients. 

Geo}\^ia. — All recovered patients must be discharged by the 
superintendent, under rules prescribed by the trustees. The 
trustees may also discharge, upon the certificate of medical officers, 
harmless incurable patients. 

Idaho. — Patients must be discharged upon recovery. 

Illinois. — Patients may be released on parole for any term not 
exceeding three months. The superintendent may discharge a 
patient who is not insane or one who has recovered, or one who is 
so far improved as to be capable of taking care of himself and not 
unsafe to the public. No person charged with crime may be dis- 
charged until notice has been given to the court having jurisdiction 
of the case. When notified that a patient has been discharged as 
cured, the judge of any court must make an order restoring the 
patient to his civil rights. A provision also exists for the after- 
care of patients by a member of the staff of physicians of the insti- 
tution whenever the superintendent deems it necessary. 

Indiana. — The patient must be discharged by the superintendent 
when he recovers. If necessary his sanity must be established by 
an inquest in the same manner as his insanity, or the patient may 
be discharged to the custody of his friends if they are willing and 
able to care for him. 

Iowa. — Any person who is cured must be discharged by the 
superintendent with a certificate to that effect, a copy of which is 
to be forwarded to the clerk of the district court from which the 
patient was committed. This certificate restores him to his civil 
rights. Relatives of any unrestored patient can also remove him 
if he is not dangerous to be at large. No patient under criminal 
charge or conviction may be discharged without an order from the 
circuit court. 

Kansas. — The board of control may release patients on parole. 
Authority to discharge is vested in the board of control, but may be 
delegated to the superintendent. The grounds for discharge must 
be that the person is not insane, or that he has recovered, or that 
he is so far improved as to take care of himself, or that his friends 
request the discharge and in the opinion of the superintendent no 



340 INSTITUTIONAL CARE OF THE INSANE 

evil consequences are likely to follow it, or that there is no prospect 
of recovery and his room is needed for another patient. No patient 
who is violent, dangerous, unusually troublesome or filthy in his 
habits may be discharged from a state institution and sent back to 
any county institution. No person who is not recovered or is 
charged with crime may be discharged until after lo days' notice 
to the probate judge. Upon proper notice to the probate judge that 
the patient is cured, he must order a restoration of his civil rights. 

Kentucky. — The superintendent may permit the friends of the 
patient to remove him permanently or for such length of time as 
the superintendent may deem prudent. No person is discharged 
cured except by the authority of the superintendent. Any patient 
admitted to the hospital under criminal charge must be delivered to 
the penitentiary or to the jail of the county whence he came, upon 
recovery. 

Louisiana. — Authority to discharge patients upon recovery or 
for other reasons is vested in the superintendent subject to the 
order of the respective boards. 

Maine. — A temporary leave of absence may be granted to a 
patient by the superintendent in charge of a guardian, relative or 
friend for a period not exceeding six months. A patient committed 
may also be discharged by a justice of the Supreme Court. 

Maryland. — Patients may be removed on leave of absence or 
parole for a period not exceeding 30 days. If the patient remains 
away 60 days a new commitment is required. Patients may be 
discharged upon recovery. 

Massachusetts. — The State Board of Insanity may permit a 
patient boarding in a family to leave such custody in charge of a 
guardian, relative or friend for a period not exceeding one year. 
The superintendent of the hospital may parole an inmate for six 
months and receive him again without a new commitment. No 
unrecovered patient who is violent or dangerous can be discharged. 

The superintendent of a public institution when authorized by 
the trustees or State Board of Insanity, or a judge of probate or 
justice of the Suj^ireme Court, may discharge an inmate who will be 
properly cared for elsewhere or whose detention is no longer neces- 
sary for his own welfare or the safety of the public. 

Michigan. — There is a provision for the parole of patients for 30 
days. Patients may be discharged on recovery or if not detrimental 



CONDITIONS OF DISCHARGE 341 

to the public welfare, or if, after a hearing in court, such recovered 
patient can obtain an order from the court which will grant the 
restoration of his legal rights. 

Minnesota. — Parole is granted to patients for six months. 
Recovered patients must be discharged. 

Mississippi. — Recovered, incurable or harmless patients are 
discharged. 

Missouri. — The superintendent may parole any patients when it 
seems best for them and may discharge any who are, in his opinion, 
fully restored to reason. 

Montana. — Commissioners of insanity must discharge every 
person in fit condition to be at large. 

Xebraska. — Cured patients must be immediately discharged. 
Relatives may remove harmless, incurable patients by consent of 
the board of trustees. Any person except a homicide may be 
removed to the county of his residence upon an application on the 
part of his friends. Incurable, harmless patients must be dis- 
charged to make room for recent cases. 

Nevada. — No provision for parole or discharge is made in 
Nevada. 

A'ew Hampshire. — Any justice of the Supreme Court may parole 
a patient and may also revoke the parole. Any person may also be 
discharged by consent of three trustees, by the Commission of 
Lunacy or by a judge of the Supreme Court. 

A'ezv Jersey. — On certificate of complete recovery from the 
director of the hospital, the managers may discharge any patients 
except those under criminal charge. They may also discharge 
unrecovered patients or return them to the almshouse of the 
covmty. No provision exists for parole. 

A^ew Mexico. — Patients must be discharged when they recover. 

New York. — Patients may be paroled for six months, during 
which time the hospital is not liable for their expenses. The 
superintendent may discharge any recovered person except a 
criminal. He may also discharge a dotard, one not insane, or an 
unrecovered patient, if he deems it safe for him to be at large and 
his friends are willing to take care of him. Any judge of a court 
of record may discharge after a hearing. The Lunacy Commission 
may discharge all patients improperly detained. 

North Carolina. — A probationary discharge may be given for 
30 days by the superintendent. Three directors of the hospital may 



342 INSTITUTIONAL CARE OF THE INSANE 

discharge a patient found to be sane, or recovered, or safe to be at 
large. 

North Dakota. — A cured patient is to be discharged. Incurable, 
harmless persons may be removed by relatives with the consent of 
the trustees. Any person uncured and deemed unsafe to go at 
large may be discharged by the Commission of Insanity and pro- 
vided for in the county institution. 

Ohio. — A patient may be paroled for not more than 90 days with 
the consent and advice of the Board of Administration. The super- 
intendent may discharge uncured patients except one with suicidal 
or homicidal tendencies. All recovered patients must be discharged. 

Oklahoma. — Recovered patients may be discharged on the rec- 
ommendation of the superintendent. 

Oregon. — Recovered patients must be discharged, also other 
patients whenever the superintendent may think the best interests 
of the state institution require it. If a patient is discharged cured, 
all legal disabilities are removed. 

Pennsylvania. — All persons restored to reason excei)t the crim- 
inal insane are to be discharged. If the patient seems to be losing 
health under hospital treatment, any law judge upon application 
may investigate the matter and order a discharge. 

Rhode Island. — Parole may be given for a period not exceeding 
six months. Unrecovered patients may be discharged upon the 
recommendation of the superintendent and trustees by an order 
from the Supreme Court. Persons who have placed an insane 
person in the hospital and have volunteered to assume temporary 
responsibility for his support may remove him. 

South Dakota. — Cured patients must be discharged ; uncured, 
harmless patients may be removed by their friends. Uncured, 
dangerous patients may be removed to the county of their residence 
by commissioners of insanity at the request of friends. 

Tennessee. — Patients may be removed whenever in the judg- 
ment of the superintendent and the president of the board of 
trustees it is deemed judicious, proper and for the interests of the 
hospital, the patient and the community for them to leave the hos- 
pital. Private patients may be paroled for 30 days. 

Texas. — All persons except those charged with or convicted of 
crime may be discharged by the trustees upon the recommendation 
of the superintendent. 



CONDITIONS OF DISCHARGE 343 

Utah. — The judge of a court of record may return a patient upon 
satisfactory evidence that his friends will give him the proper care. 
A criminal patient charged with crime or convicted cannot be dis- 
charged unless by an order of a court having jurisdiction. Non- 
insane persons or one not judicially detained must be discharged 
by the court. 

Vermont. — The board of supervisors of the insane may dis- 
charge any person, subject to revocation. The superintendent of 
the Brattleboro Retreat may parole a patient for 30 days. Persons 
who are recovered are discharged on the order of the supervisor 
with the consent of the superintendent. 

Virginia. — The superintendent of the hospital may grant a 
parole for such time as may benefit the patient. When an insane 
person is restored to sanity he must be discharged. Any person not 
charged with crime or convicted of it may be discharged to the 
custody of friends, also one deemed harmless and incurable. 

Washington. — Any person may be discharged when the super- 
intendent deems it expedient. 

West Virginia. — Any person in a hospital or jail who is restored 
to sanity must be discharged by the examining board. If in the 
hospital, by the circuit court ; if in jail, by the circuit court or county 
court. Any insane person except one charged with crime or con- 
victed of it may be delivered to any friend who will give a bond 
for his care. Harmless incurable insane persons may be delivered 
without bond to any friend able and willing to take care of them. 

Wisconsin. — The superintendent of the state hospitals and of the 
Milwaukee County Hospital may parole a patient for a period of 
two years. If he can then no longer be at large with safety to the 
public, he may be returned without new proceedings. After two 
years the presumption of insanity ceases and he must be regarded 
sane. Harmless incurable insane must be discharged by the super- 
intendent, to create room for more hopeful cases. 

Wyoming. — No legal provision for parole or discharge of pa- 
tients exists. 



IV. 
ADMISSION OF VOLUNTARY PATIENTS. 

No section of any law seems more vague and lacking in uni- 
formity than that governing the admission of voluntary patients to 
institutions for the insane, as now found in the statutes of the 
various states. 

t^ut of the 48 states and the District of Columbia, the following 
17 states and the District of Columbia already have provisions of 
law permitting the admission of voluntary patients, viz. : California, 
Colorado, Connecticut, District of Columbia, Illinois, Maryland, 
Massachusetts, Michigan, Minnesota, New Jersey, New York, 
North Carolina, Ohio, Pennsylvania, Rhode Island, \^ermont, Wis- 
consin and \'irginia. 

California enacts that a person may be admitted voluntarily 
" who is suffering from mental disease, but is competent to make 
a written application." He cannot be retained more than seven 
days except upon legal proceedings required by considerations of 
safety. 

In Colorado, a voluntary patient may be admitted '' whose mental 
disease is not such as to render it legal to grant a certificate of 
insanity." If such person desires to leave the institution he must 
give three days' notice. 

In Connecticut, a voluntary patient may be admitted " whose 
condition is not such as to render it legal to grant an order as to his 
insanity " ; such person cannot be detained against his will more 
than three days. 

In Illinois voluntary patients have been admitted to institutions 
since 1893. The law provides that " any person in the early stages 
of insanity who may desire the benefit of treatment in a state or 
licensed private hospital as a voluntary patient may be admitted on 
his own written application accompanied by a certificate from the 
county court stating that he is a private or county patient." Such 
patient, if admitted, shall have the same standing as any other 
private or county patient, provided that he has the right to leave 
the hospital at any time upon giving three days' notice to the 
superintendent. 



ADMISSION OF VOLUNTARY PATIENTS 345 

During the biennial period of January i, 191 1, to December 31, 
19 1 2, voluntary patients were admitted as follovi^s to the various 
institutions : 

The Elgin State Hospital 30 

Kankakee State Hospital 86 

Anna State Hospital 21 

Watertown State Hospital 144 

Peoria State Hospital 118 

The Chester State Hospital and the Chicago State Hospital had 
no voluntary patients. 

In Cook County the lack of voluntary patients is ascribed to the 
fact that a former judge of the county court of Cook County did 
not approve of the law. 

In ^Maryland, which seems to have had one of the earliest enact- 
ments on the subject, a voluntary patient " may be admitted who 
makes application in writing, provided the expense is borne by the 
person, his relatives or friends." He cannot be detained more 
than three days against his will. 

In Massachusetts, the provision is simply that the " superin- 
tendent may receive any person as a voluntary patient who makes 
application and is mentally competent to make it." He cannot be 
detained against his will more than three days. 

In Michigan there is a curious provision that voluntary patients 
" who are afflicted mentally or with serious nervous disability but 
who are not insane," must present certificates signed by two phy- 
sicians having legal qualifications, " stating that the person needs 
asylum treatment, but is not insane." No provision exists for his 
discharge from the institution if he desires to go away. It is =tated 
that if he is found insane he must have legal proceeding,*; instituted 
to effect his regular admission. 

In Minnesota, the provision is that any person believing himself 
to be afflicted with mental disease, upon written application signed 
in the presence of two witnesses not employees or officers of the 
institution, may be received into a detention hospital. If he de- 
mands his release and is deemed unsafe to be at large, he must be 
examined by the state hospital commission within three days and 
committed or discharged. 

In New Jersey, " any resident of the state believing himself 
about to become insane and desiring to submit himself to treat- 
29 



346 INSTITUTIONAL CARE OF THE INSANE 

ment," if he is competent to make an application, may be a volun- 
tary patient. He must pay his own expenses and cannot be de- 
tained more than three days after giving notice. 

In New York it is provided that " any suitable person who 
voluntarily makes written application " and is " competent to make 
it " may be admitted to a state hospital or licensed private institu- 
tion. He cannot be detained more than 10 days against his will. 

In Pennsylvania, persons who are threatened with mental dis- 
orders and voluntarily place themselves in institutions for the 
insane, may be received for a period of one month or less by an 
agreement which must specify the time and be signed by them at 
the time of admission. 

In Ohio, " a person in an incipient stage of mental derangement 
may apply " and be received as a voluntary patient, but he cannot be 
kept more than 60 days. 

Five voluntary patients only can be admitted to any one hospital 
and none can be admitted if the quota of the county is full. This 
seems to render the provision of very little practical benefit. 

In Rhode Island, a voluntary patient is received into institutions 
" who is desirous of submitting himself to treatment and makes a 
written application, but whose mental condition is not such as to 
render it legal to grant a certificate of insanity." He cannot be 
detained against his will more than three days. 

In Vermont any voluntary patient may be received " who seeks 
treatment and makes written application " for admission without 
certificates of physicians. He cannot be detained more than 48 
hours against his will. 

In Wisconsin, a voluntary patient who is " insane or suffering 
from mental disorders may, upon his written application, sup- 
ported by certificates of at least two physicians, be admitted " to a 
state institution. He cannot be detained more than five days 
against his will. 

In Virginia the law allows the superintendent to receive volun- 
tary patients without legal commitment, when their reception 
will not crowd out patients who are committed by commissions 
appointed to ascertain their insanity. Voluntary patients are ad- 
mitted by the superintendent, who fixes the rates and collects them. 
They are the only class of patients who pay for their treatment in 
the state institutions of Virginia. 



ADMISSION OF VOLUNTARY PATIENTS 347 

It will be noticed that the phraseology of the different laws is 
vague and not always clear and that in some states it must be 
clearly shown by medical certificates that the person is not insane 
and yet is a fit subject for hospital treatment. In other states the 
patient must he clearly insane and his insanity must be shown by 
legal certificates. In others the patient must he insane hut not in 
such manner as to he certifiable hy physicians. Much of the con- 
fusion undoubtedly arises from the fact that, according to the 
decision of a number of appellate courts, the confinement of an 
insane person is not legal unless the person is dangerously insane 
either to himself or to the community. In several states unques- 
tionably the reference to the insanity not being of such character 
as to be legally certified to has reference to this legal decision. In 
some states indigent patients can be admitted in this manner ; in 
others provision is made that the expense of the voluntary patient 
shall be paid by himself or his friends. 

In Michigan the original provision for the admission of volun- 
tary patients provided that they should not be insane and that 
under no circumstances could they be supported by the state. A 
subsequent section of the law provided that voluntary patients 
could be cared for at the expense of the county and subsequently 
of the state, but the Attorney General declared it contradictory and 
invalid. 

Among the earliest provisions is that of the State of Maryland. 
During the past five years a large number of other states have 
adopted the provision for the voluntary admission of patients. It 
is to be hoped that within the next five years all states may have a 
similar provision of law. 



V. 
CARE OF THE CRIMINAL INSANE. 

The development of public opinion as to the care of insane 
criminals in the United States was a plant of slow growth. 

As we have seen, in an early day in Maryland, Connecticut, 
Rhode Island and New York, little thought was given to the mani- 
fest inhumanity of attempting to care for the insane and still less 
to care for insane criminals in connection with the jail, house of 
correction or penitentiary ; in fact many people believed that insane 
criminals were justly punished by imprisonment or even by hang- 
ing for crimes committed when manifestly insane. 

In an early number of the American Journal of Insanity an 
account is given of the execution of an insane man in Connecticut, 
who had killed his wife under the delusion that she was a witch and 
went to execution with his mind wholly under the influence of his 
delusion and unable to appreciate that he was on the way to the 
gallows. There have been many instances where insane murderers 
have been confined in a state prison for life with no attempt to 
alleviate the hardships of prison life or to give them the care or 
treatment demanded by their condition. In many parts of the 
United States it has been customary in fact to dispose of imbeciles, 
often manifestly of the lowest grade of intellect and guilty of 
minor offenses because of a lack of reasoning power and manifest 
irresponsibility, by committing them to prisons or houses of correc- 
tion. Some years ago an eminent alienist declared that he much 
preferred sending an insane criminal to a state prison than to an 
institution for the insane because he believed the discipline and 
severity of prison life more serviceable than the laxity of discipline 
inherent to the hospital treatment of the insane. 

At the time the great wave of public interest in the insane spread 
over the country and state institutions were established, the pre- 
dominant idea in the public mind was to provide a place where the 
curable insane could be cured. There was little thought for many 
years of making better provision for the chronic insane of any 
class, whether criminal or otherwise. 



CARE OF THE CRIMINAL INSANE 349 

One of the first institutions for the criminal insane was estab- 
lished in connection with the state prison at Weathersfield, Conn., 
where, in an enclosure surrounded by a wall similar to that of the 
prison itself, the insane were to be cared for under the same con- 
ditions as to discipline, control and resjimen as ordinary convicts. 
Through some freak in the legislative mind this building was never 
occupied and in 1859 was made a store-house for the penitentiary. 

In New York, about 1850, a law was passed which provided for 
the transfer of insane criminals from the jails and prisons to the 
Utica State Hospital. The number of such transfers, however, 
became so great as to threaten to fill the hospital to its utmost 
capacity so that cases of acute disease for which it had been estab- 
lished could no longer be received. It was accordingly deemed 
advisable to establish at Auburn an asylum in connection with the 
state prison. This first asylum for insane criminals on a hospital 
basis was opened in 1855 and did excellent service until the increas- 
ing number of insane criminals required the establishment o a 
much larger institution at Matteawan. Even here the burden of 
caring for insane criminals, and especially for criminals who 
remained insane and required care after the expiration of their 
terms of sentence, became so great as to necessitate the establish- 
ment of another institution for the custody of insane criminals 
of the chronic class at Dannemora, in Northern New York, in 
proximity to the Clinton state prison. To-day, therefore. New 
York has two large hospitals for insane criminals. 

In 1882, the State of Michigan established, in connection with 
the house of correction at Ionia, an institution for the criminal and 
dangerous insane, which has since been in successful operation. 
Recently it has been thought that its proximity to a house of cor- 
rection interfered with its usefulness and it has been removed a 
distance of two or three miles from the house of correction, 
although still remaining at Ionia. 

In Alabama the criminal insane are cared for separately in con- 
nection with the Tuscaloosa State Hospital. Upon recovery they 
are returned to prison. 

In California a hospital for the chronic criminal insane is under 
construction at Folsom in connection with the state prison. Insane 
criminals may, however, be transferred to any one of the state 
hospitals for the insane. 



350 INSTITUTIONAL CARE OF THE INSANE 

In Colorado the State Hospital maintains a separate ward for the 
criminal insane. 

In Connecticut an insane criminal is sent to the Connecticut Hos- 
pital at Middletown. If a person is acquitted of a criminal charge 
on the ground of insanity he must be committed to an asylum. 

In the District of Columbia a separate ward is maintained at the 
Government hospital for insane criminals. 

In Georgia insane convicts are kept and treated at the State 
Sanitarium. 

In Illinois an institution for the dangerous insane is established 
at Chester. 

In Indiana a hospital for insane criminals is established in con- 
nection with the state prison at Michigan City. 

In Iowa a department for insane convicts exists at the peniten- 
tiary at Anamosa. 

In Kansas a state asylum for the dangerous insane has been 
established in connection with the state penitentiary. 

In Louisiana the State Hospital for the Insane has a ward for 
the criminal insane at Jackson. 

In Maine an insane department for criminals is established in 
connection with the state prison at Thomaston. 

In Massachusetts there is a large institution for the criminal 
and dangerous insane at Bridgewater. 

In Minnesota a ward exists for the care of the criminal insane in 
connection with St. Peters State Hospital ; there is also a depart- 
ment for insane criminals at the state prison at Stillwater. A 
separate institution for the criminal insane has been recommended 
by the State Board of Control. 

In New Hampshire the criminal insane are committed to the 
New Hampshire State Hospital at Concord. 

In New Jersey the state has under construction in connection 
with the Trenton State Hospital a house for the detention of 
convicts and insane criminals. At present they are cared for at the 
two state institutions, Morris Plains and Trenton. 

In North Carolina there is a hospital for the dangerous insane 
at Raleigh. 

In Ohio, a hospital for the dangerous and criminal insane is 
being constructed at Lima.' 

^ This hospital was opened for the reception of patients, February 15, 
1915. 



CARE OF THE CRIMINAL INSANE 351 

In Pennsylvania there is a hospital for the criminal insane at 
Farview, in the northeastern portion of the state. 

In Rhode Island the criminal insane are sent to the prison insane 
ward at the State Hospital or to the state almshouse. 

In Vermont a ward especially for the criminal insane is main- 
tained at the State Hospital. 

In Virginia there is a special ward for white criminal insane in 
connection with the Southwestern Hospital for the Insane at 
Marion and a similar department for the colored criminal insane 
at the Central State Hospital at Petersburg. 

In Washington a department for the criminal insane exists in 
connection with the state penitentiary. 

In the other states provision is made for the transfer of insane 
criminals to the state hospital for the insane. 



CHAPTER X 

IMMIGRATION AS A FACTOR IN THE 
INCREASE OF INSANITY 



I. 

IMMIGRATION AND THE CARE OF THE INSANE. 

The introduction of discordant elements foreign to the estab- 
lished customs of the Anglo-Saxon population resident in the 
country and the consequent social and political unrest, mainly 
exemplified in the " American," or so-called early " Know Nothing 
Party," led Congress in 1838 to consider the necessity of the 
prevention of the introduction of undesirable persons into the 
United States from foreign countries, but no action was taken. 
At the same time the Judiciary Committee of the U. S. Senate 
recommended legislation prohibiting the entrance of idiots, lunatics 
and those suffering from incurable diseases or convicted of crime. 

Finally in i860 the practice of several continental governments 
in pardoning murderers with the provision that they emigrate to 
the United States, led to the adoption of a resolution of protest* 
and two years later a statute encouraging emigration was repealed. 
The continued agitation at last led to the Act of 1882, since which 
time immigration has been a subject of repeated legislation and 
wide discussion. 

The first declaration on the subject of restrictive immigration 
legislation by the Association of Medical Superintendents of 
American Institutions for the Insane occurred at the thirty-eighth 
annual meeting of the Association in Philadelphia, in May, 1884. 

It took the form of the following series of resolutions introduced 
by Dr. Foster Pratt of Kalamazoo, and finally, after a wide dis- 
cussion, unanimously adopted : 

Whereas. By a comparison of the statistics of the " defective classes " 
of our population, as shown by the eighth, ninth and tenth censuses, it 
appears : 

First. That the proportion of insane to the total population in the 
United States is rapidly increasing; and 

' See " Growth of the Law of Insanity," chapter IX, page 325. Case of 
John Pastano. 



356 INSTITUTIONAL CARE OF THE INSANE 

Second. That a prominent factor in this increase is the large defective 
element found among the " foreign born " who have emigrated to us 
since 1847 and 1848, and who now constitute one-eighth of our total 
population, but who furnish, approximately, one-third of our criminals, 
one-third of our paupers, and one-third of our insane ; and 

Whereas, While the cost of buildings to suitably keep and the annual 
tax to properly maintain these classes falls wholly and heavily on the 
several states and territories, they are inhibited by federal laws from 
enacting and enforcing effective measures to prevent or mitigate these 
evils so far as they are caused by immigration ; therefore. 

Resolved, That the Association of Medical Superintendents of Ameri- 
can Institutions for the Insane respectfully urge the Congress of the 
United States to give early and earnest attention to this important sub- 
ject, to the end that immigration laws may be enacted by it which, while 
they do not unnecessarily obstruct the immigration of healthy and self- 
dependent persons, will effectively prevent the emigration and the exporta- 
tion to our ports of the so-called " defective classes " of Europe and Asia. 

Resolved, That in furtherance of the object, a copy of these resolutions 
and preamble be forwarded to the President of the United States and to 
the President of the Senate and the Speaker of the House of Representa- 
tives at Washington for consideration by them and by Congress ; also to the 
Governor and presiding officers of the legislatures of each state in the 
Union, and to each State Medical Society, that they and the people they 
severally represent, who are most affected by the pecuniary burdens and 
by the physical and moral evils caused by the unrestricted and unregulated 
immigration, may be moved to take such steps as they deem best to 
secure early and efficient action by Congress (with whom alone is the 
power) to abate the great and growing evils to which public attention is 
hereby called. 

In the discussion prior to the adoption of Dr. Pratt's resolutions 
it was indicated that it had been the practice of certain European 
countries to unload upon the American States the contents of their 
workhouses. It is true that the legislative enactment of August 3, 
1882, charged the Secretary of the Treasury with the duty of 
supervising immigration and prohibited the landing of lunatics, 
idiots and persons liable to become a public charge. But the law 
was simply directory. The provisions for its execution were inade- 
quate. There was no penalty imposed upon those who did not obey 
it. Hence further restrictions were suggested and finally put into 
adequate form by Chapter 551 of the Laws of 1891 (March 3). 

This made it a misdemeanor to bring in any of the above pre- 
scribed classes and imposed a fine of one thousand dollars on any- 
one guilty of so doing. It provided. Section 11. that any alien 



IMMIGRATION AND THE CARE OF THE INSANE 357 

entering- in violation of law could be returned at any time within 
one year thereafter, at the expense of the person or persons, ves- 
sels, transportation company or corporation responsible for his 
entry, and further, that those becoming public charges within one 
year from causes existing- prior to landing should be considered as 
having entered in violation of law. 

This statute continued in force unchanged until the act of 
March 3, 1903. This excluded idiots, imbeciles, feeble-minded 
persons, epileptics, and insane persons, persons insane within five 
years previous to landing, those having had two or more previous 
attacks at any time, paupers and all others liable to become a public 
charge. By Section 17 the officers of the United States Marine 
Hospital Service were charged with the duty of determining 
the mental condition of all immigrants. Section 20 provided that 
aliens coming to the United States in violation of law, who were 
found to be public charges from causes existing prior to landing, 
could be deported at any time within two years. Section 21 author- 
ized the Secretary of Commerce and Labor to deport any alien 
within three years if entering in violation of law. 

The amendment of February 20, 1907, Section 2, made manda- 
tory the exclusion of idiots, imbeciles, the feeble-minded, epileptics, 
insane, all who had been insane during five years previous to 
landing, persons having had two or more attacks of insanity at any 
time, or who were likely to become a public charge, as well as 
individuals not comprehended in the foregoing excluded classes, 
but found to be suffering from mental or physical defects of such 
a nature as to afifect their ability to earn a living. 

Section 20 provided that an alien entering in violation of law 
or becoming a public charge from causes existing prior to landing 
should, upon the warrant of the Secretary of Commerce and Labor, 
be taken into custody and deported to the country from whence he 
came, at any time within three years after the date of his entry 
into the United States. The cost of the removal was to be a charge 
upon the owners of the vessel or transportation line immediately 
responsible. When the mental or physical condition of the alien 
was such as to require personal care or attention, the Secretary of 
Commerce and Labor was authorized to employ a suitable person 
for that purpose. The practical operation of the law was further 
provided for by rules and regulations to be formulated by the Com- 



358 INSTITUTIONAL CARE OF THE INSANE 

missioner General of Immigration. In cases becoming a public 
charge from prior causes, the application for deportation must be 
accompanied by 

(a) An explicit statement that the alien is a public charge, 
where and how, and, if in an institution, the date of admission 
thereto. 

(b) A full and accurate statement of the alien's disability, 
mental or physical ; also whether or not a complete cure is possible, 
and if "yes" when, and if not, whether a partial cure may be 
expected, and to what extent the alien will thereafter be self- 
supporting. Also in insane cases, if recovered or apparently recov- 
ered from the attack, whether new attacks are to be expected. 

(c) Whether or not the disability described constitutes the sole 
cause why the alien is a public charge ; any other causes to be 
stated. 

(d) Whether the causes which render the alien a public charge 
existed prior to landing, or arose subsequent thereto, and in the 
former case the reason in detail justifying such a conclusion. 

At the sixty-eighth annual meeting of the American Medico- 
Psychological Association held at Atlantic City, N. J., May 28, 
1912, the Committee on Immigration, Dr. Edward N. Brush, 
Chairman, submitted a series of resolutions in part as follows : 

That the entry of a large number of insane and mentally defective 
immigrants menaces the mental health of the country in this and suc- 
ceeding generations, and by overtaxing the resources of our public insti- 
tutions tends to produce lower standards of care, and that while the federal 
statutes provide for the exclusion of the insane and mentally defective 
immigrants, it would be more humane as well as more effective to reject 
such insane and mentally defective immigrants at the port of such entry, 
rather than wait until they and their families have established a residence 
in the country. And that it has been shown that the facilities for the men- 
tal examination of arriving immigrants are inadequate, and that the safe- 
guards for the humane care of those deported are insufficient. 

It was therefore recommended that the American Medico-Psy- 
chological Association should urge Congress to provide for mental 
examination of arriving immigrants by physicians in the I^^^nited 
States Public Health and Marine Hospital Service, trained in the 
diagnosis of insanity and mental defect, and that adec[uate facili- 
ties be provided for the detention and examination of immigrants 
suspected of mental defects, and for the safe and humane return 
to their homes of those excluded. 



IMMIGRATION AND THE CARE OF THE INSANE 359 

Also that aliens who have been permitted entrance to the country 
and who become insane and show any mental defect within at least 
three years after landing, should be deported, unless it shall be 
shown conclusively that such insanity or mental defect has resulted 
from causes arising since the landing of said aliens, and that the 
question of such insanity or mental defect as well as of insanity, 
or mental defect in aliens seeking to land, should be authoritatively 
decided by physicians of experience and training in psychiatry. 

Further, that the barbarous custom of deporting insane or men- 
tally defective aliens without accompanying nurses or qualified 
attendants, of his or her own sex, and of experience in caring for 
such cases, is a reflection upon the intelligence and humanity of 
the country, and should at once be discouraged. 

Also that the fine imposed upon transportation lines for bringing 
mentally defective immigrants into the country is inadequate and 
should be at least twice the amount now imposed, and that the 
same fine should be imposed for bringing insane immigrants into 
the country. 

In the discussion, prior to the adoption of the committee's 
resolutions, especial stress was laid upon the deplorable lack of 
care meted out to the unfortunate deported insane alien during his 
passage to Europe, and the methods employed after landing to 
convey him to his former place of residence. 

Until 1907 all insane immigrants were deported, wdthout regard 
to their condition, by the first returning vessel available and aliens 
for whom warrants had been issued by the Department of Com- 
merce and Labor were deported to the port at which they had 
embarked ; their return to their own homes depending upon the 
humanity or good nature of the transportation companies. 

Under these conditions many insane aliens were not reaching 
their homes, and complaints received led the New York State 
Charities Aid Association to investigate the matter. This investi- 
gation made it apparent that it was necessary some action should 
be taken, and accordingly the immigration law was amended at the 
instance of the State Charities Aid Association in 1907. The 
amendment provided that when the chief medical officer of a hos- 
pital or a medical officer of the Public Health or Marine Hospital 
Service certified that an insane alien was not in condition to attempt 
the journey alone, such insane alien should be accompanied by an 



360 INSTITUTIONAL CARE OF THE INSANE 

attendant. This was done for about six months when the steam- 
ship companies protested against the law on the ground that it 
was " too expensive." 

A conference was then called by the authorities at Washington, 
the steamship companies and the State Charities Aid Association 
being represented. 

At this conference it was decided that the intent of the law would 
be carried out by having a paper in four parts accompany deported 
persons. The first part of this paper was to be signed by the Com- 
missioner of Immigration, stating the alien's condition. The 
second part was to be an acknowledgment on the part of the trans- 
portation company of the receipt of the alien. The third was to be 
a statement of the master of the vessel regarding the care given 
on the voyage and a receipt by the European forwarding agent. 
The fourth part was to be signed by the relatives of the alien or the 
proper authorities acknowledging the receipt of the alien in his 
home. 

It soon became apparent that old conditions were returning, 
however, and it was proposed that the law be changed, so that the 
Secretary of Commerce and Labor should be obliged to provide 
competent attendants when needed and that the expense should be 
borne by the government. 

On June 28, 1912, a conference was held between Mr. Edward 
B. Sanford, attorney, representing the steamship companies, Mr. 
Goodwin Brown and Dr. George S. Campbell, representing the 
State Hospital Commission of New York, and former Congress- 
man William S. Bennett, at which the following agreement was 
made concerning the deportation of some two thousand alien 
insane then in the New York State hospitals: 

The steamship companies agreed to take the alien insane at the 
ordinary steerage rate if they are notified before sailing of the 
patient's condition and assured that he is not dangerous. The 
commission will turn over to each of the lines the patients who 
came to this country by that line and will furnish information as to 
the identity and place of destination of each alien. The passage 
money is to be paid by the state. It was estimated that from six 
months to a year would be required to deport the whole number. 

At the 69th annual meeting of the American Medico-Psycho- 
logical Association held at Niagara Falls, Canada, June 10, 1913, 



IMMIGRATION AND THE CARE OF THE INSANE 361 

the Committee on Immigration reported that immigration bills, 
containing four of the six recommendations made by the com- 
mittee, had been passed by both houses of Congress. Other pro- 
visions in these bills, notably a literacy test, unfortunately resulted 
in their veto by President Taft. The recommendations of the com- 
mittee, however, received the strong approval of the President, who 
stated in his veto message he regretted that it was impossible to 
sign a bill carrying these excellent provisions. 

The committee further stated that bills had been introduced in 
the Senate by Senators Dillingham and Overman and in the House 
of Representatives by Mr. Roddenbury, which embodied all the 
recommendations of the committee.' As the whole matter was still 
undecided, a motion to continue the Committee on Immigration 
was unanimously carried. 

^ Nothing further has been accomplished as regards the passage of the 
revised Immigration bill, as recommended by the Committee on Immigra- 
tion of the American Medico-Psychological Association. Principally by 
reason of a literacy test, the bill met the fate of its predecessor, and was 
vetoed bv President Wilson. 



30 



II. 

THE ALIEN-BORN IN RELATION TO THE COST OF 
STATE CARE. 

The State of New York has been more interested in the question 
of the aHen insane in the state hospitals than any other state. This 
is by reason of the fact that the port of New York receives at least 
eight-tenths of all the immigrants coming to this country, while 
about 26 per cent of the total become residents of the State of New 
York. It can therefore be safely stated that conditions existing in 
New York, while extreme, are nevertheless representative of con- 
ditions existing in other parts of the country, and will serve to 
show the question at issue in the clearest possible light. 

As far back as 1847 the State of New York created a commission 
of emigration, whose duty it was to properly safeguard and help to 
employment all the immigrants arriving at the port of New York 
for a period of five years after their arrival, the funds for which 
purpose being created by a small commutation payment by each 
immigrant. Between the years 1847 and 1855 this state emigration 
commission paid to the State of New York $2,250,000 as the 
state's share of the cost of the support of those aliens who within 
five years had become a public charge.' 

In 1890 there were 16,006 insane in the various institutions under 
the State Commission in Lunacy, and 23,778 in 1900, an increase of 
48.05 per cent. On December 31, 1903, there were 1 1,61 1 foreign- 
liorn patients in the New York State hospitals for the insane. In 
addition there were on that date 4025 patients of foreign ])arentage 
and 874 of mixed parentage, only 55.4 per cent of the patients in 
the public and private institutions of the state at that time being of 
native parentage. 

In 1910 the total number of patients reported under care was 
32,658, or 37 per cent more than in 1900, with a growth of popula- 
tion amounting to 25 per cent during the same period. In February, 
1912, there were 31,432 patients in the fourteen state hospitals. 
41.09 per cent of whom were of foreign birth. 

' Speech of Hon. Lathrop Brown, of New York, in the House of Repre- 
sentatives, January 30, IQM- 



ALIEN-BORN INSANE IN RELATION TO COST OF CARE 363 

During the year ending September 30, 191 1, the state disbursed 
approximately $7,378,000 for the care of the insane. It will readily 
be seen that a large proportion of this expenditure is made neces- 
sary by providing for the maintenance of aliens/ 

During the year 1904 an act was passed by the State Legislature 
amending the insanity law and providing for the examination of 
immigrants at the port of New York to ascertain their mental con- 
dition. Provision was made in Section 18 of this act for the 
establishment of a board of alienists for the examination of the 
insane, idiotic, imbecile, and epileptic immigrants, such board to 
consist of a chief examiner and two assistant examiners to be 
appointed by the State Commission in Lunacy. This board was 
required to inspect and examine immigrants coming into this coun- 
try at the port of New York, for the purpose of determining 
whether they came within the above mentioned classes. It was also 
the duty of the Board of Alienists to notify the State Commission 
in Lunacy of the location of all insane patients who were non- 
residents of the State of New York, the board receiving the neces- 
sary authority from the commission in all suitable cases for the 
investigation and removal of all such cases. The board was 
directed to notify the proper authorities of the United States 
having control of the enforcement of the immigration laws at such 
port and arrange for the deportation of such alien insane in accord- 
ance with the provisions of the federal enactment. 

In 1906 the board was officially recognized by the federal 
government, and an invitation was extended by the authorities of 
Ellis Island " To witness at the pleasure of the board the medical 
examination of immigrants with special consideration for their 
mental condition, and if any case should come to their notice after 
having passed these surgeons, the government would be pleased 
to have their attention called to the matter, when the case would be 
re-examined." 

The board has arranged for the deportation of insane aliens who 
had been admitted to the various state hospitals as well as to the 
observation wards at Bellevue and Kings County hospitals. As a 
result of the activities of the board during the seven years ending 
September 30, 191 1, it investigated 6910 cases of alien and non- 

^ " Immigration and the Insane in the State of New York," James V. 
May, M. D., New York State Hospitals Bulletin, April, 1912. 



364 INSTITUTIONAL CARE OF THE INSANE 

resident insane and of this number 3718 were removed from the 
state. This represents an approximate saving on maintenance, 
based on the per capita cost of caring for the insane, of practically 
$685,490 during the years 1905- 191 1. If the cost of construction, 
etc., is included, the total saving as a result of the removals of 
these aliens and non-residents is approximately estimated at 
$3,25 1 ,390. This saving has been effected at a total cost of $2 1 1 ,600, 
this amount representing the total expenditures of the Board of 
Alienists during that time. When the fact is considered that the 
approximate per capita cost of caring for the insane at the present 
time is $190 per annum, and the estimated average hospital life of 
each insane person is about nine years, the magnitude of the 
expenditures required for his support will be readily appreciated.' 

The study made by the Federal Census Bureau in 1904 showed 
that the relative frequency of insanity among the foreign born in 
the various states differed in accordance with the nationalities 
composing the foreign-born population. Taking the country as a 
whole, however, the foreign born, which in 1900 formed only 19.5 
per cent of the total population 10 years of age and over, con- 
tributed 34.3 per cent of the insane. 

Of the 5700 first admissions to the fourteen state hospitals of 
New York for the year ending September 30, 191 1, only 1224, or 
21.47 per cent, were native born of native parentage, while 1481 
were native born of foreign or mixed parentage. No less than 
4218 patients were either foreign born or children of parents one 
or both of whom were foreign born. Taking the two generations 
into consideration, the foreign element contributed 74 per cent of 
the first admissions. 

Comparing the percentages of nativity among the first admis- 
sions with the percentages among the general population, we find 
that the native-born population, which constituted 70.1 per cent of 
the whole, contributes 51.28 per cent of the first admissions, while 
the foreign-born population, which constitutes 29.9 per cent of 
the whole, contributes 48.02 per cent of the first admissions. The 
frequency of insanity among the foreign born throughout the 
states is therefore 2.19 times as great as among the native born. 

• Communication from the State Commission in Lunacy to Hon. John 
A. Dix, Governor of the State of New York, February 27, 1912. 



ALIEN-BORN INSANE IX RELATION TO COST OF CARE 365 

The rate of insanity among the total foreign born in New York 
City is 2.48 times that of the native born. 

Of the 1560 re-admissions for the year ending September 30, 
1911, 984, or 63.1 per cent, were native born and 573, or 36.8 per 
cent, were foreign born, while the birthplace of three patients could 
not be ascertained. Both parents of only 496 patients, or 31.8 per 
cent, of the whole number of re-admissions were native born. Of 
the 806 who were residents of Xew York City at the time of admis- 
sion, 416, or 5 1.6 per cent, were foreign born. Both parents of only 
100, or 12.4 per cent, of the Xew York City re-admissions were 
native bom.^ 

The data of the federal census of 1910 concerning the nativity of 
the foreign-born insane in institutions in the United States are 
not available, but taking the figures from the federal census report 
of 1904, we find that in that year there were in all institutions 
(civil, criminal and private) in the United States 47,078 foreign- 
born insane patients. 

In 1912 the New York State Hospital Commission estimated the 
net cost for each alien patient for that year to be $279.18. On this 
basis the net cost to New York State for 1912 of its 9241 alien 
insane would be $2,579,902.38.^ 

The fundamental reason for the existence of the problem of the 
alien insane is the helpless position of the states, under the present 
law, as to the admission and expulsion of aliens. 

The state has no jurisdiction over immigration, other than that 
incident to the exercise of its police power, and has neither the right 
to prevent undesirable aliens from coming within its borders, nor 
authority to remove them therefrom once they have entered. The 
power to regulate immigration is vested in the federal government 
alone, which by its laws and rules determines what aliens shall be 
admitted to or removed from the several states. 

The states must therefore receive within their borders all such 
aliens as the United States may admit thereto, and must apply to 

^ " A Statistical Study of the Foreign-Born Insane in the New York 
State Hospitals," by Horatio M. Pollock, New York State Hospitals Bulle- 
tin, April, 1912. 

^ " Report of the Alien Insane in the Civil Hospitals of New York State," 
Albany, N. Y., 1914. 



^66 INSTITUTIONAL CARE OF THE INSANE 

the federal authorities to remove therefrom any aHens found to be 
undesirable. 

Ahhough it takes five years for an alien to become a citizen, 
nevertheless an alien by being three years within a state, neither de- 
siring nor intending to become a citizen, at no time contributing by 
the payment of direct taxes to the support of the commonwealth and 
being unavailable for the military or civil duties of a citizen, may, 
if he becomes insane, by operation of the Immigration Act, acquire 
such rights as against the state that it is powerless to expel him 
from its boundaries or to compel his return to the country of which 
he is a citizen, but, for its public safety and welfare or from humani- 
tarian motives, must care for and maintain him so long as he 
chooses to remain. 

It would seem, however, that but few of the states fully realize 
the importance of deportation and the saving resulting therefrom, 
for the report of the Bureau of Deportation for 191 3 states that 
during the 12 months ending September 30, 1913, the total number 
of insane aliens deported from all ports of the United States upon 
federal warrant as being insane from causes existing prior to land- 
ing numbered 641 ; that of those 379, or 59.12 per cent, were de- 
ported from New York State, leaving 262, or 41 .88 per cent, as rep- 
resenting the efforts of all the remaining states. According to the 
figures of the census of 1910 New York State had 16.7 per cent of 
the insane in institutions in the United States, while in 1904, the last 
year of which the figures are available. New York was caring for 
25.2 per cent of the foreign-born insane.^ 

As of interest in this connection we have appended herewith a 
statement of the numljcr deported to other states and countries by 
the Massachusetts State Board of Insanity since its establishment 
in 1898, giving this information by years. In addition, figures 
showing the number deported by the United States Commissioner 
of Immigration from institutions under the supervision of the 
Massachusetts State Board of Insanity since 1904, the first year the 
figures were published, are given. 



' J bid. 



ALIEN-BORN INSANE IN RELATION TO COST OF CARE 



367 



Deportations from AIassachusetts to Other States and to Foreign 

Countries. 



Year. 


By State Board of Insanity. 

^- , 

Other States. Other Countries. 


Total. 


By United States 

Commissioner of 

Immigration. 


1899 


41 


84 


125 




1900 


50 


79 


129 




19OI 


56 


84 


140 




1902 


36 


60 


96 




1903 


45 


82 


127 




1904 


36 


61 


97 


30 


1 90s 


60 


63 


123 


45 


1906 


50 


79 


129 


43 


1907 


55 


60 


115 


60 


1908 


58 


43 


lOI 


IZ 


1909 


55 


96 


151 


84 


19IO 


63 


79 


142 


82 


I9II 


49 


54 


103 


62 


I912 


66 


66 


132 


84 


I913 


69 


96 


165 


109 


Total 


789 


1086 


1875 


672 



There is also appended the following extracts from biennial 
report of the deportation agent of the State Board of Control of 
Minnesota for the period ending July 31, 1914: 

deportations. 

During the year ending July 31, 1913 "jj 

During the j-ear ending July 31, 1914 143 

destination of deported patients. 

1913 



Austria 

Belgium 

Canada 3 

Denmark i 

England i 

Finland 2 

France i 

Germany i 

Holland 

Hungary i 

Italy I 

Norway 2 

Russia I 

Scotland 

Sweden 4 

Switzerland 2 

Other states 57 



1914 

4 

2 



107 
143 



368 INSTITUTIONAL CARE OF THE INSANE 

During the same period the United States deported 33 cases, 
without expense to the state except cost of maintenance pending 
deportation. 

There was expended by the state during the period the sum of 
$7755.06; this amount divided by the number of deportations 
made by the state gives a per capita cost of deportations of $41 •47- 

Improved reciprocal relations with contiguous states have been 
in part responsible for these results. 



CHAPTER XI 

INSANITY AMONG NEGROES, INDIANS, CHINESE 
AND JAPANESE IN THE UNITED STATES 



INSANITY AMONG THE NEGROES. 

In Volume I, of the Journal of Insanity, pages 287-288, occurs 
the following note : 

" Insanity is rare we believe among Africans. Cinquery and 
others of the Amistad negroes, when in this country a few years 
since, visited the Retreat for the Insane at Hartford, Conn., and 
saw many of the patients there. They informed the writer of this 
article that insanity was very rare in their native country. Most 
of them had never seen an instance. Cinquery stated, however, 
that he had seen one case." 

Whatever might be the prevalence of insanity among the 
negroes in Africa, it was very early recognized among their de- 
scendants in this country, as is shown by the records of South 
Carolina, which contain in an act for the relief of the poor, enacted 
in 1 75 1, a section "providing for the subsistence of slaves who 
may become lunaticks while belonging to persons too poor to care 
for them." By this section justices of the peace and overseers of 
the poor are required upon notice " to cause such lunatic slaves to 
be secured in some convenient place in the parish, as well as to 
prevent their doing mischief, and for the better subsisting of such 
lunatic slaves, the expense to be borne by the parish." 

Again it is found that at a meeting of the court of directors of 
the Hospital for the Insane at Williamsburg, Va., held on April 
19, 1774, Charity, a free mulatto woman, brought to the hospital 
from the County of Richmond, was found to be a person of insane 
and disordered mind, and it was ordered that she be received into 
the hospital. 

This hospital was the first in America to care for the colored 
insane. 

In the History of the Western State Hospital for the Insane at 
Staunton, Va., published in full in a subsequent volume, it is stated 
that from its opening in July 1828, "No distinction of race was 
made among those who partook of the charity of the state. In the 
case of white or black, rich or poor, the only plea to be made was 
that of need." 



372 INSTITUTIONAL CARE OF THE INSANE 

At first there seem to have been no compHcations or difficulties 
arising from the mingling of the races. In 1848, however, when 
the asylum was enlarged we find that the court of directors placed 
itself on record as follows : 

" That owing to the construction of the buildings here, it would 
be utterly impracticable to make suitable provision therein for the 
accommodation of colored patients; and were it practicable we 
should deem it highly inexpedient that the two classes of un- 
fortunates be placed within one and the same enclosure." 

As a result of this recommendation, the General Assembly of 
Virginia passed an act on January 22, 1850, appropriating $11,500 
to provide free accommodations for insane negroes at Williams- 
burg. Prior to this, in 1846, the General Assembly had passed a 
bill permitting insane slaves to be received in the Williamsburg 
Asylum, but only when there was sufficient room after the white 
insane had been provided for.^ 

About the same period, the South Carolina Legislature passed 
an ordinance, December 19, 1848, entitled " An Act to Authorize 
the Admission of Persons of Color Into the Lunatic Asylum." 

It is of interest to note that the first patient received into the 
Eastern Lunatic Asylum at Lexington, Ky., which was opened on 
May I, 1824, was " a colored woman named Charity, aged 21, who 
had never been able to walk or talk, nor had she ever partaken of 
soHd food." 

It is very evident from the above examples that insanity existed 
among the negroes in the Southern states prior to emancipation, 
and that in some states at least legislative relief was granted to 
them. With the exception of the specific Act of 175 1 in South 
Carolina, the care offered in most cases applies only to free 
negroes, the masters being supposed to care for their mentally 
infirm slaves. No doubt some of the negroes admitted to the Wil- 

^ In 1855-56 a special building was built for the colored insane at the 
Government Hospital, Washington, D. C, which the superintendent stated 
was the " first and only special provision for the suitable care of the 
African when afflicted with insanity which has yet been made in any part 
of the world." This was not the case, however, for in 1853 the colored 
insane of Virginia were being cared for in a separate building at the 
Eastern Asylum, at Williamsburg. (See "History of the Central State 
Hospital, Virginia," by W. F. Drewry, M. D., in a subsequent volume.) 



INSANITY AMONG THE NEGROES 373 

liamsburg Asylum were slaves whose maintenance was paid for 
by their masters, but in most cases it seems certain that the insane 
slaves were cared for on their own plantations, where the cost of 
their maintenance could be reduced to a minimum. 

The subject of mental affections among the negroes, owing to 
the rather wide-spread belief that such disorders have rapidly 
increased since their emancipation, has been given of late years a 
great deal of attention. 

Dr. William F. Drewry, superintendent of the Central State 
Hospital, Petersburg, Va., in a paper on the " Care and Condition 
of the Insane in Virginia," ' gives a series of reasons to account for 
the causes which have operated with such disastrous results to 
the negro's mind since his emancipation. Briefly stated they are 
as follows : 

1. During slavery there were doubtless many mildly insane and 
weak-minded and senile negroes, who were cared for by their 
owners and never reported. In those days the census reports were 
very imperfect. 

Old inhabitants tell us that before the "6o's an insane negro was 
a rarity, and the facts all go to show that the disease was by no 
means prevalent among the race. The regular, simple life, the 
freedom from dissipation and excitement, steady and healthful 
employment, enforced self-restraint, the freedom from care and 
responsibility, the plain, wholesome, nourishing food, comfortable 
clothing, the open-air life upon the plantation, the kindly care and 
treatment when sick, in those days, all acted as preventive meas- 
ures against mental breakdown in the negro. 

2. The negro, as a race, after the war was not prepared to care 
for himself or to combat the new problems in his life. He became 
a prey to his own weaknesses and passions and to whatever con- 
stitutional deficiencies he had. He suffered from ignorance and 
disregard of hygienic laws, promiscuous over-crowding in living 
quarters, and laxness in the bonds of the family circle. Habits 
of indolence, intemperance, immorality; often insufficient and 
unwholesome, cheap and adulterated food and whiskey, have all 
operated against the physical and mental welfare of the negro. 

^ Read at the 35th National Conference of Charities and Correction, 
Richmond, Va., May, 1908. 



374 INSTITUTIONAL CARE OF THE INSANE 

And in recent years he has become, in a large measure, a victim to 
cocaine and other (lrn,<;- habits. 

3. Hereditary deficiencies and unchecked constitutional diseases 
and defects, with their direful influences, transmitted from parent 
to offspring, with an almost desperate disregard of consequences, 
play now a hazardous part in the causation of insanity and epilepsy 
in the race. It has only been in recent years that hereditary influ- 
ences have been a significant factor. 

4. A better understanding now than formerly of the nature of 
insanity, a more general knowledge and appreciation of the bene- 
fits derived from hospital care and treatment, and an increased 
confidence in the humane methods usually in vogue, tend to 
increase the number of commitments in the negro race as well as 
the white. 

5. The crowding in unsanitary hovels in cities, idleness and 
irregular habits have had tremendous effect in undermining the 
health of the negro and making him an easy subject to mental 
disease. 

6. A willingness and even desire on the part of many negroes 
nowadays to shift from themselves to the state the burden of the 
care of those who are weak-minded or senile or dotard ; and the 
simplicity of present medico-judicial methods of commitment, as 
compared with former complicated judicial procedures, which 
were not unlike a trial for a criminal ofifense, also help to account 
for the increased number of patients in our hospitals. 

7. The regular life and constant care and treatment of the 
chronic insane in a hospital tend to prolong life, and thus cause 
an ever increasing accumulation of chronic incurable cases, who 
are a charge ever afterwards upon the state. 

It is fact worthy of observation that the greater number of 
insane negroes come from the uneducated, thriftless classes and 
from the old and decrepit ; comparatively few patients come from 
the educated and more prosperous classes. A well nourished, 
intelligent, thrifty negro, leading a correct life, is probably little 
more liable to become insane than a white person under similar 
conditions, except for the fact that the powers of resistance and 
endurance are weaker in his race than in the white race. In short, 
the negro is to-day an easier prey to constitutional diseases than 
the whites and succumbs more readily to strain, stress and disease. 



INSANITY AMONG THE NEGROES 375 

According to a paper on " Psychoses Among Negroes — A Com- 
parative Study," ' by E. M. Green, M. D., Clinical Director Georgia 
State Sanitarium, Milledgeville, Ga., at the beginning of the 
year 1870, 380 patients were confined in his institution, of whom 
321 were white and 59 were colored. During the succeeding ten 
years the proportion of negroes increased more rapidly than did 
the whites, and in 1880 the ratio between the races was one to four. 
In 1900 a ratio of i to 2.2 was reached, and this has remained 
practically stationary since that time. 

Dr. Green finds that certain psychoses appear more often in one 
race than in the other and states that " at the outset we must recog- 
nize that in every consideration of the negro race we are dealing 
with two distinct classes, one composed of those of mixed blood 
and the other of pure or comparatively pure blood." 

In the psychoses accompanying pellagra he finds that " it is 
probable that admissions to a hospital for the insane do not 
accurately number the cases of mental disorder associated with 
pellagra. The most prominent manifestations of such disorders 
are a delirious state, a period of clouded consciousness with hal- 
lucinations and apprehensiveness, and active delirium which neces- 
sitates constant care. Under such conditions the patient cannot be 
kept at home unless his relatives are able to provide the necessary 
care and treatment. The negro as a rule, being unable to supply 
either, is compelled to have the patient committed to a hospital 
where he can be cared for without cost." 

Dr. Green gives a table showing the forms of psychoses found 
in 21 19 negroes admitted. In view of the generally accepted 
opinion regarding the use of liquor and drugs by the negro race 
this table is of great interest. It shows that alcoholic psychoses 
are found three times as often in the white as in the negro, and 
that of the cases admitted during a period of five years, only si.x 
negroes have suffered from drug psychoses, as opposed to 142 such 
cases occurring in the white. As regards the statements made as 
to the enormous increase in the use of cocaine by the negro, he 
states that in 2119 cases, cocaine addiction appeared once alone, 
and once in combination with other drugs as an etiological factor 
in psychoses. He explains these figures by the fact that very few 
negroes earn more than enough to furnish their bare necessities, 

'Journal of Nervous and Mental Disease, Vol. XLI, No. 11, Nov., 1914. 



376 INSTITUTIONAL CARE OF THE INSANE 

and that the cost of alcoholics to enable them to indulge their 
appetite over a protracted period, is prohibitive ; and it is upon the 
basis of chronic alcoholism that the alcoholic psychoses develop. 
In the case of cocaine, the habitual use of the drug unfits the 
individual for work and when work ceases money to purchase the 
drug fails, so that the habit does not become established. 

In the white race even the high grade imbecile sooner or later 
finds his way to an institution where his talents may be put to the 
best advantage, but in the negro a moderate mental defect is apt 
to be less noticeable. As a rule the true condition is not appreciated 
until an episode of some kind renders commitment necessary. For 
these reasons the number of negro patients assigned to the imbe- 
cility and idiocy group is smaller than the white. 

It must be remembered that the negro is of a simple nature, giv- 
ing little thought to the future, accepting responsibility thought- 
lessly, and desiring only the gratification of the present. He is 
easily roused to happiness, and his unhappiness is transitory, dis- 
appearing as a child's when other interests attract his attention. 
Suicide, though not unknown, is an extremely rare occurrence in 
the negro race. He is seldom depressed, and finds pleasure from 
occasions which would give rise to sadness in the whites. He is 
superstitious, and believes in ghosts, witches, spells, poisons and 
conjuring. Towards members of his own race he is suspicious, 
fearing bodily harm, and attributes any misfortune or sickness to 
the effects of witchcraft. From childhood he is threatened with 
beasts, spooks and witches, and the chief subjects of the conversa- 
tions he hears are of ghosts and conjuring. He is early familiar 
with the meaning of signs, and the various acts by which he may 
escape bad luck. When he reaches the age of puberty, and ideas 
of love and sexual gratification come into consideration, the influ- 
ence of charms and of herbs is resorted to to bring his desires to 
fruition. To quote from Dr. Green : 

" The fear of the supernatural, the suspicions of his fellows and 
the necessity of guarding at all times against bad luck and the 
machinations of enemies, play a part in bringing about psychoses 
which more frequently than in the white takes the form of dementia 
praecox." 

Dr. Green further adds that " the discrepancy between the ratio 
of manic depressive psychoses in the two races is still more strik- 



INSANITY AMONG THE NEGROES 3/7 

ing than in dementia praecox. Tlie negro race is emotional; in 
grief noisy and obtrusive, it is of a superficial character and soon 
passes; in happiness active, boisterous, restless, manifesting in- 
creased muscular activity, it is aroused with little provocation and 
reaction to it is excessive. Slight pleasure causes exaggerated 
evidence of elation. We have seen that the manic forms of the 
psychosis occur in a much larger proportion to the depressive 
forms than is the case with the white race, and this is only what 
we should expect to find in a race whose characteristics are such 
as have been enumerated above." 

In the Northern and Western states, where racial antipathy is at 
a minimum, and where the negro forms a small ratio of the general 
population, no special provision is necessary for his care in hos- 
pitals for the insane. In the South, however, a very difYerent con- 
dition prevails. In this region it seems to be the unanimous 
opinion of the authorities that the separation of the white and 
colored patients is to the advantage of both races. According to 
Powell,^ " the distinction has been made for social reasons alone. 
Consequently we find to-day in most Southern asylums four 
departments, whereas in other institutions two suffice." 

Three states, Maryland, Virginia and North Carolina, have 
separate hospitals devoted to the care of the colored insane exclu- 
sively. And one state, Alabama, has a separate hospital for their 
care but under the same management as the hospital for white 
patients. Most of the states, however, care for their negro insane 
in separate departments of the hospitals devoted to the care of the 
white insane as well. This is the older custom which was in force 
from the beginning of institutional care of the insane in the 
Southern states. 

In Virginia, the colored insane were cared for in the Eastern 
Lunatic Asylum at Williamsburg until December 17, 1869. On 
that date, at the suggestion of Dr. Stribling, and by order of 
Major-General Canby, Military Commander, an asylum for the 
colored insane of the state was established near Richmond. This 
hospital, known as Howard's Grove Asylum, was the first institu- 
tion in America to be devoted to the care of the negro insane 
exclusively. This institution was finally located at Petersburg, 
and opened for the admission of patients in April, 1885. It is now 

* Transactions American Medico-Psychological Association, Vol. 4, p. 125. 
31 



378 INSTITUTIONAL CARE OF THE INSANE 

known as the Central State Hospital, Petersburg. In 19 ii there 
was constructed at this institution a building exclusively for the 
colored criminal insane. The Eastern Asylum for the Colored 
Insane, Goldsboro, N. C, was the second hospital to be de- 
voted to the colored insane exclusively, being provided for by 
the North Carolina Legislature of 1875, and opened for the recep- 
tion of patients on August i, 1880. 

The Hospital for the Negro Insane of Maryland was established 
by act of the General Assembly of Maryland on April 11, 1910, 
which made an appropriation of $100,000 for the purchase of land 
and the erection of buildings. On December 13, 1910, a site was 
purchased at Crownsville, Anne Arundel County, and temporary 
buildings were erected for the admission of patients. On July 21, 
1911, 16 patients were admitted. 

We have already seen that South Carolina, by an ordinance of 
December 19, 1848, authorized the admission of persons of color 
into the " Lunatic Asylum." In a report to the regents of the same 
institution, in 1869, w^e find Dr. Parker, the superintendent, urging 
better provision for persons of color. He states that until the close 
of the war the number in the asylum never exceeded five, but that 
during the year 1869 the number admitted was 29, and that the 
buildings appropriated exclusively for their care were almost full. 
He recommended that a separate building of brick, properly 
planned and arranged, be erected as soon as possible for the exclu- 
sive use of the negro insane. 

There seems to have been recommendations to the same effect 
made annually by successive boards of regents and superintend- 
ents, but such a building was not erected until 1897. 

This building, a three story brick structure, was used for the 
accommodation of the negro males. The females were housed in 
the old asylum building, the original structure built in 1822. 

In 1866 the Legislature of Georgia appropriated $11,000 for an 
insane asylum for negroes, and the building was located on the 
grounds of the asylum for the whites. In 1870 the Legislature 
appropriated $18,000 for the enlargement of this building, and in 
1879, $25,000 for the same purpose. 

In 1 88 1 an appropriation of $82,166 for a new building was 
made. These several enlargements provided for 541 negroes. In 



INSANITY AMONG THE NEGROES 379 

1893 the Legislature appropriated $100,000 for the erection of 
additional buildings for the white and colored insane. 

In Louisiana negro patients are received at the Louisiana Hos- 
pital for the Insane, Pineville, under the same circumstances and 
are given the same treatment as white patients. They are, how- 
ever, domiciled in separate buildings. 

In Alabama a few negro patients are cared for in " The Bryce 
Hospital." The Mt. Vernon Hospital, 56 miles distant from the 
" Bryce Hospital," is devoted exclusively to the care of negroes. 
An exceptional feature in the Alabama hospitals is they are under 
the same management, one superintendent acting for both hos- 
pitals, but with an assistant physician at each hospital. 

The Mt. Vernon Hospital was provided for by the Legislature 
of 1900-01. Most of the buildings have been built by hospital 
employees, and are one story cottages, no one of which holds more 
than 150 patients. 

In Florida the negro insane are cared for in special buildings at 
the Florida Hospital for the Insane, Chattahoochee. 

In Mississippi the negroes are cared for in separate buildings 
at the State Insane Hospital at Asylum. 

In Tennessee there is a detached building, erected in 1895, ^^ 
the Eastern Hospital for the Insane at Knoxville, to care for the 
negro insane of East Tennessee. A similar building was built in 
1868 at the Central. Hospital for the Insane at Xashville. At the 
Western Hospital for Insane, at Bolivar, the negro patients are 
accommodated in a separate wing of the main building. 

The Western State Hospital, at Hopkinsville, Ky., has separate 
buildings for the colored male and female patients. 

In West Virginia the colored insane are cared for in a special 
building at Weston. 

According to a paper on " Psychosis in the Colored Race," ' by 
Mary O'Malley, M. D., " the census of i860 shows that there was a 
total of 766 insane colored patients in institutions in the United 
States in a population of 4,031,830, and the census of 1910 shows a 
total of 13,567 insane colored patients in institutions m the United 
States in a population of 9.827.733. From i860 to 1910 the colored 
population increased 1 1 1 per cent, and in the same time the num- 
ber of colored insane increased 1670 per cent." 

^ The American Journal of Insanity, \'olume LXXI, page 309. 



380 IXSTITUTIONAL CARE OF THE INSANE 

According to the census of 1910, the ratio for the insane per 
100,000 population, is, outside the South, higher for negroes than 
for whites in every geographic division. In New England, for 
instance, the ratio is 105.9 P^^ 100,000 whites, as compared with 
153.8 per 100,000 for negroes, and in the Middle Atlantic division 
the ratios are 75.3 per 100,000 and 105. i per 100,000 respectively. 
In the South Atlantic division, on the other hand, 59.7 out of 
100,000 whites were admitted to insane asylums, as compared to 
46.2 out of 100,000 negroes. In the East South Central division 
the number of admissions per 100,000 population was 47.5 for the 
w^hites and 35.8 for negroes ; and in the West South Central 
division it was 38.8 and 17.3 respectively. There are some individ- 
ual Southern states, however, in which, as in the North, the ratio 
of admissions to hospitals for the insane is higher for negroes than 
for whites. These states are Delaware, Virginia, West Virginia, 
Florida, Kentucky and Tennessee. 



II. 

INSANITY AMONG THE NORTH AMERICAN INDIANS. 

In Volume I of the Journal of Insanity, upon page 287, occurs 
the following note : 

" Dr. Lillybridge of Virginia, who was employed by the govern- 
ment to superintend the removal of the Cherokee Indians in 
1827-8-9, and who saw more than 20,000 Indians and inquired 
much about their diseases, informs us he never saw or heard of a 
case of insanity among them." 

" Dr. Butler, who has been a devoted missionary and physician 
among the Cherokees for about a quarter of a century, informs us 
in a recent letter that he has as yet seen no case of decided insanity 
among them, though he has occasionally seen them delirious when 
sick of other diseases ; and adds that an intelligent chief, a man 
now 80 years old, told him that " he had never known a case of 
insanity among his people, such as he had seen in the hospital at 
Philadelphia." 

In the early settlement of the country the Indians were in a 
sense segregated, and did not come into very close contact with 
their superior, the white race. Accustomed to their old traditions 
they kept their own counsel, and if any one of their number became 
insane they either secluded him or managed to take care of him 
without outside interference. It was usual for them to attribute 
the origin of insanity to the action of some evil charm, or the 
administration of some noxious potion, obtained by an enemy 
from one of the many " medicine men." There was also an implicit 
belief that if a counter-remedy or charm could be procured from 
a " medicine man " having greater power than the one from 
whom the injurious charm had been derived, the patient could be 
quickly cured. 

Cases of acute mania, especially if violent, were supposed to be 
possessed by a cannibal spirit, or windigo, and being thus a menace 
to other members of the tribe were promptly shot or otherwise dis- 
posed of without ceremony. 

In a paper on "Witchcraft in Certain Legal and ^ledical Rela- 
tions," Dr. C. B. Burr recounts the following : 



^82 INSTITUTIONAL CARE OF THE INSANE 

"A venerable priest ministering to the necessities of the mem- 
bers of a fast disappearing tribe of Indians, in the lower St. 
Lawrence, told me of unique methods in vogue among them for 
overcoming the evil spirit ' windigo,' supposed to possess the 
body of one insane and to eat out the souls of others. It was the 
aim of the Indians to lose in the woods or otherwise dispose of 
one afflicted with a mental infirmity. On one occasion the priest 
heard by chance of a puerperal woman suffering from mania. 
Approaching her cabin about which many " braves " were stand- 
ing, he heard the words " the cure is coming.'' The reason for 
the warning was soon apparent. Inside the cabin he discovered 
the woman bound to a chair, placed back up and in a sloping posi- 
tion. Round her neck was a cord which extended through a chink 
in the rear wall of the cabin. At the other end of this cord there 
had been relays of Indians, who made it taut from time to time. 
The priest extricated the squaw from her perilous position, 
soothed and cared for her." 

From an extract furnished by Dr. T. J. \V. Ikirgess, from "A 
Narrative of the Adventures and Sufferings of John R. Jewitt, 
Only Survivor of the Crew of the Ship Boston, During a Captivity 
of Nearly Three Years Among the Savages of Nootka Sound," an 
interesting account is given of a case of insanity as regarded by 
the Indians at that time. As a matter of interest to those to whom 
a copy of Jewitt's story is not accessible, a synopsis of the extract is 
given in an Appendix, on page 393. 

Dr. Burgess states that " from information derived from Pro- 
fessor Hill-Tout, Judge Howay of New Westminster, British 
Columbia, and others, it would seem that the Indians looked upon 
insanity as they did any other sickness. It was simply the "bad 
medicine " which some enemy had caused to affect him. Its com- 
parative rarity is shown by the fact that they had no conception 
of how to treat it. Many things, however, go to show that the 
Indians were well enough acquainted with insanity to regard 
unusual conduct as a proof of its existence. For example, they 
regarded the famous botanist, David Douglas, who did so much 
work on the Pacific Coast, as weak in the head. Nor is it at all 
unnatural that, seeing a man roaming about the country in all 
directions to gather plants, mosses, lichens, seeds and insects, 
whereas they were wont at that time, 1827-1833, to see men hunting 



INSANITY AMONG THE NORTH AMERICAN INDIANS 383 

fur-bearing animals only, they should regard him as not quite right 
mentally, and so designate him the " grass man." * 

The story of Mark Jack, an insane Indian of the Tuscarora tribe, 
who was under treatment at the Utica State Hospital from 1851 
to 1874 and at the Willard State Hospital from 1874 until his 
death there eight years later, is of interest, because it seems to show 
that insanity among Indians follows much the same course as 
among white persons. 

He was a farmer of common school education, but considered 
one of the most intelligent men of his tribe, of temperate habits 
and a church member. A maternal uncle was an imbecile and a 
maternal aunt was "singular" — a half-brother by his mother's 
former husband was insane. He first showed insanity at the age 
of 22 years, at a time when he was attempting to learn English 
and to study mathematics in 1843, and for two years he had periods 
of excitement, followed by intervals of quiet in which he was able 
to do farm work. About the third year he became so violent and 
incoherent in his talk as to require to be kept in close confinement 
in a log hut, and remained there for six years. His excitement 
was called by his Indian associates " conreaya bonos," or madness. 
Being a ward of the state, he was admitted on the order of Gov- 
ernor Washington Hunt. At the time of his admission his 
brother stated that two other members of the same tribe had been 
insane, one of whom recovered and the other died. His condition 
during the 31 years of institutional treatment was one mostly of 
quiet dementia, with rare intervals of noisy excitement. His 
habits became untidy and eventually convulsive seizures developed. 
He was probably in a stage of terminal dementia at the time of his 
admission to the hospital at Utica. It is evident that he had a 
strong hereditary tendency to insanity which was developed by 
his efforts to enter upon studies for which he was not fitted. 

As to insanity among the Indians of the present day, there seems 
to be some diversity of opinion. Dr. Felix M. Adams, superinten- 
dent of the East Oklahoma Hospital for the Insane, Vinita, Okla., 
states that " from what investigation I have made I find that 
insanity is not very prevalent among the full-blooded Indians." 

^ See " The Care of the Insane in Washington " in a subsequent volume, 
case of " Archibald Petton." 



384 INSTITUTIONAL CARE OF THE INSANE 

Dr. D. W. Griffin, superintendent of the Oklahoma Hospital for 
the Insane at Norman, Okla., writes under date of April 8, 1914, 
as follows : 

" Since my connection with the insane of this state (Oklahoma) 
I have come to the belief that the Indians are as subject to insanity 
if not more so than the white citizen. 

" We find now that as the country is being taken up by the 
white man and the Indian becoming more enlightened and accus- 
tomed to the white race, educationally and otherwise, he is more 
ready to submit a case of insanity for consideration of the courts. 
And we find therefore that the percentage of insanity among the 
Indians is certainly equal to that of the white man.^ 

" If it were possible to take into account feeble-mindedness and 
epilepsy among the Indians, the percentage would be considerably 
greater." 

In 1898- 1899 the United States Government established at 
Canton, S. Dak., an asylum intended for the treatment of 
insane Indians exclusively, especially those Indians who retain a 
tribal relation and for whom, as they are considered wards of the 
government pure and simple, the government under treaty regula- 
tions is considered to be responsible. 

There had been more or less insanity among the Indians on the 
different reservations for many years, and the relatives and friends 
who, among civilized communities, are held responsible for these 
unfortunates, were absolutely unfit for such responsibility, because, 
in addition to lack of experience, of proper accommodations and 
of food, all Indians have a superstitious horror of persons showing 
any peculiarity of manner or conduct. As previously stated, they 
believed that such persons were possessed of a devil and should be 
put out of existence or left entirely alone. 

No Indian agency of the government was prepared to assume 
the care of insane people. It was already obvious that among full- 
blooded Indians there were types of insanity corresponding identi- 
cally with types of mental and nervous trouble among white people, 

' According to the census of 1904, there were in hospitals for the insane 
on December 31, 1903, 58 Indians ; while in 1904 there were admitted to 
hospitals 27 Indians. The census for 1910 shows that out of a total popu- 
lation of 265,683, there were in hospitals for the insane 166 Indians ; a 
ratio of 62.5 per 100,000 of population. 



INSANITY AMONG THE NORTH AMERICAN INDIANS 385 

even the most civilized. The former superintendent of the asylum 
at Canton, S. Dak., investij^ated three cases of insanity reported 
to him which were caused by financial anxiety, pure and sim- 
ple, brought on by the prospective loss of property as definitely 
as any observed upon the Stock Exchange or Board of Trade in 
New York or Chicago. Cases of insanity among Indians from 
financial embarrassment are doubtless rare. There are, however, 
cases of insanity among full-blooded Indians due to domestic 
infelicity, to loss of children and other relatives, and to religious 
mania, as well as other types as clear and distinct as they are among 
white men. There are also cases of alcoholic mania as well as of 
homicidal and other criminal manias. Mental and nervous dis- 
orders, including epilepsy, are prevalent. These statements refer 
only to full-blooded Indians. Among those of mixed blood all 
types of insanity are present. 

The establishment of the asylum at Canton was a most beneficent 
and humane expenditure on the part of the government for the 
protection and care of an absolutely helpless and dependent people. 

In all of the 120 years of the active and settled policy of the 
government in its business relations with the American Indian, no 
steps had been taken by the government for the protection and 
care of this most unfortunate and helpless class among the 
American Indians, until the establishment of the Asylum for the 
Insane Indians at Canton, S. Dak. 

We have appended herewith as a separate chapter liberal 
extracts from a paper entitled " Insanity Among the Indians at the 
Asylum for Insane Indians, Canton, S. Dak.," by H. R. Hummer, 
M. D., superintendent. 



III. 

INSANITY AMONG THE INDIANS AT THE ASYLUM 
FOR INSANE INDIANS, CANTON, S. DAK/ 

In an Indian population of more than 300,000 in the United 
States there were June 30, 191 1, 58 insane Indians in the asylum 
at Canton, S. Dak. ; 52 applications on file, necessarily deferred 
because of limited accommodation; 20 or more cases in various 
state institutions and upwards of 20 others cared for by relatives 
or friends of the more civilized class. This gives a total of 
upwards of 150 known cases of insanity, a ratio of i to 2000. As a 
matter of fact, judging from the reports of employees and sane 
Indians of several of the 140 schools and reservations throughout 
the United States, there must be at least double this number, or a 
ratio of i to 1000 of the population. For instance, there are from 
15 to 20 epileptics on the Flathead Reservation in Montana, the 
majority of whom present symptoms of mental alienation. Pos- 
sibly this may be accounted for by the fact that this tribe binds the 
heads of the infants to make them flat, from which custom they 
received their name. Scarcely an employee or an enlightened 
Indian from any of the reservations visits this asylum who does 
not afiirm that he knows of from one to five cases on that reserva- 
tion who should properly be in the asylum. It must be remembered 
that this is the judgment of laymen, but there must be a founda- 
tion of fact behind this judgment. These cases are not brought to 
the attention of the various superintendents or physicians, owing 
to the reticence and superstitions of the Indians. It is not sur- 
prising that superintendents and physicians do not find them when 
one considers the enormous territory under their jurisdiction. 

Another factor of importance is the faith of the older full- 
bloods in their own medicine men, who treat insane cases by 
incantations, herbs and other means. Recently, commissions have 
been appointed by the Indian Ofiicc. to visit the various schools 
and reservations to determine from an examination what Indians 
are competent to receive lands and to become self-supporting citi- 

' By H. R. Hummer, M. D., superintendent. 



INSANE INDIANS IN SOUTH DAKOTA 387 

zens. In the findings of one commission, out of 700 Indians on a 
single reservation 350 were found to be competent ; 250 incom- 
petent; and the status of 100 was undecided at the time of the 
report. These 250 incompetents were probably not so designated 
because of ignorance or lack of education alone, but many 
were undoubtedly incompetent from idiocy, imbecility, consti- 
tutional inferiority, epileptic psychosis, organic brain disease, senile 
dementia and other forms of mental disease, unrecognized by a 
commission composed of laymen. It is impossible to foretell the 
results of similar commissions at other schools and agencies, but it 
is fair to assume that additional cases will be found at each. If 
this be true the estimate of i insane person in 1000 may prove far 
too low. 

In the 126 cases admitted from the opening of the asylum 
at Canton, S. Dak., to June 30, 191 1, the diagnoses in the 
records show the following types: melancholia, circular insanity, 
climacteric insanity, manic-depressive insanity, epileptic idiocy, 
epileptic dementia, epileptic imbecility, epileptic psychoses, 
amentia, imbecility, high grade congenital imbecility, alcoholic 
dementia, dipsomania, toxic insanity, alcoholic insanity, intoxica- 
tion psychoses, dementia, epilepsy, syphilitic epilepsy, epilepsy 
with hemiplegia, cortical epilepsy, traumatic epileptic dementia, 
dementia praecox, infantile spastic diplegia, spastic spinal paralysis, 
kleptomania, nymphomania, mutism, sexual neurasthenia, paresis, 
galloping paresis, syphilitic dementia. This classification ( ?) has 
been revised as accurately as the lack of records permits and at 
the end of the last fiscal year the records carried nine types, viz., 
dementia praecox, 15; the epilepsies, 14; congenital imbecility, 8; 
intoxication psychoses, 6 ; manic-depressive insanity, 5 ; senile 
psychoses, 6; arterio-sclerotic dementia, 2; hysteria, i ; paranoia, 
I. The records are far from complete or satisfactory. 

The 126 admissions were: from Arizona, 12; California, i; 
North Dakota, 7; South Dakota, 22; District of Columbia, i; 
Idaho, 3 ; Kansas, 3 ; Minnesota, 16 ; Montana, 7 ; Nebraska, 3 ; 
Nevada, 2 ; New Mexico, 8 ; Oklahoma, 2"] ; Oregon, 3 : Washing- 
ton, I ; Wisconsin, 8 ; Wyoming, 2. 

Of the tribes represented, the Sioux have contributed the largest 
number, 25, followed closely by the Chippewa w'ith 19. Then in 
order we have the Navajo, 8; Apache and Cherokee, 5 each; 



388 INSTITUTIONAL CARE OF THE INSANE 

Menominee, Osage Piute, 4 each ; Bannock, Blackfeet, Choctaw, 
Creek and Winnebago, 3 each ; Arickaree, Caddo, Chickasaw, 
Flathead, Pima, Pueblo and Seminole, 2 each ; and i each of the 
following : Arapaho, Cheyenne, Cree, Crow, Gros Ventres, Hopi, 
Kickapoo, Klamath, Mesa Grande, Modoc, Moqui, Papago, 
Pawnee, Piegan, Potawatomi, Puyallup, Quapaw, Sac and Fox, 
Shawnee, Shoshone, Umatilla, Wyandotte and unknown. It should 
be remembered that the Sioux and Chippewa are large tribes in 
the immediate vicinity of the asylum. 

The records show 13 cases due to congenital defect, 8 male and 
5 female, four of these having epilepsy as a leading causative 
factor, followed closely by epilepsy with 11 cases, 6 females and 
5 males ; third in order appears alcohol, which is charged with 
producing insanity in six cases, 4 men and two women ; senility 
ranks fourth with 5 cases, 3 females and 2 males ; arterio-sclerosis 
in 2 cases, 1 male and i female ; the puerperium in one and 
domestic diflficulties in another. This leaves 16 cases with an 
unknown etiological factor. In these cases we find heredity, head- 
injury, constitutional inferiority, prison-life, domestic troubles, 
menstrual disorders, the climacterium, worry, grief, over-eating, 
over-medication, fright, exposure, frequent pregnancies, and con- 
sanguinity in the parents, given as possible contributing factors, 
but in none is the history sufficiently clear to warrant removing 
them from the class of unknown etiology. As to heredity, one 
patient, classed as a congenital imbecile, was the offspring of 
parents who were brother and sister; a case of manic-depressive 
insanity, covering a period of 45 years, showing " insanity in the 
father's family " and " peculiarities, intemperance and melancholy 
in the mother's family '' ; one case of dementia prsecox shows a 
maternal cousin epileptic ; a congenital imbecile has a history of a 
" foolish father " ; another is the offspring of a consumptive 
mother ; an epileptic imbecile springs from a syphilitic mother ; a 
case of dementia prsecox had " a brother, aunt and uncle mentally 
unbalanced " ; and a manic-depressive case shows an " eccentric 
father and an insane grandfather," whether maternal or paternal 
is unknown. The histories are fragmentary, in many instances 
totally lacking, and in others unreliable. This may be explained 
by the fact that the Red Man is extremely reticent concerning 
insanity among his ancestors and relatives because of his super- 
stitions as to witchcraft. 



INSANE INDIANS IN SOUTH DAKOTA 389 

A case of arterio-sclerotic dementia now under treatment was 
absolutely neglected by her relatives following an apoplectic 
stroke, because another relative, dying of tuberculosis, claimed to 
have a vision of this woman, just before her death. According to 
the Indian conception, this vision proved conclusively that the 
patient was possessed of devils and had poisoned the relative. 
She would have died from neglect and exposure had it not been for 
the kindness of a more enlightened neighbor, when her relatives 
refused to go near her. Mr. GifYord, a former superintendent of 
the asylum at Canton, in the annual report for 1902 states that 
" the condition of the larger number of these patients, mentally 
and physically, when received into the asylum, indicates extreme 
neglect in their former care and treatment. Some of these unfor- 
tunate people have no relatives or friends who are responsible, 
either legally or morally, for their care and support and some 
Indians are quite superstitious regarding insanity and will have 
nothing to do with an insane relative or friend, except to get rid 
of him in the quickest and easiest manner possible." This state- 
ment is not at all exaggerated, except in a few^ cases, whose rela- 
tives have attended the Indian schools sufficiently long to over- 
come such superstitions. In these cases there is practically no 
difiference between the care given the afflicted Indian and that 
given his white brethren. It would appear that domestic difficulty 
is an especially prominent factor in the causation of mental disease 
in the Indian race. The marriage vows, generally speaking, are 
not held inviolable, with the result that it is not unusual to hear of 
children the offspring of father and daughter, brother and sister, 
and of equally close relations. This may be partially explained by 
their mode of living, in many instances all the members of the 
family living in one tepee, hogan or room, which, when taken with 
the voracious appetites and indolence of the males, causes the 
sexual function, rather than muscular action, to become a safety 
valve for the system. The amount of restraint placed upon the 
sexual desire is much less than in the white race. 

So far as sex is concerned, out of 126 cases admitted, ^2 were 
males, a percentage of 57 plus, and 54 females, a percentage of 
42 plus. 

The degree of Indian blood as a causative factor may be shown 
by the fact that out of 126 admissions, 84 were full-bloods, 38 half- 



390 INSTITUTIONAL CARE OF THE INSANE 

bloods, three less than half and one unknown, giving a percentage 
of 66 2-T, for the full bloods. 

Age as a causative factor is shown by the following table based 
on 126 admissions: Two in the first decade; 18 in the second; 28 
in the third; 36 in the fourth; 15 in the fifth; 10 in the sixth; 
7 in the seventh ; 7 in the eighth ; and 3 beyond the eighth decade. 
An old lady is 102 years old. 

Marital conditions of the 58 in the asylum June 30, 1911 : 24 
were single, 19 married, 11 widowed, i divorced and 3 unknown. 
The lack of records makes it impossible to give these data for 
all admissions. 

Symptomatology. — Indian manic-depressives present nothing 
materially different from whites afflicted with the same disease. 

I have observed no instances of imperative conceptions and the 
physical symptoms were inconsequential. 

The epileptics here differ in no manner from the white epileptics 
I have seen, except that five out of the 14 have a condition of 
hemiplegia, three of the left side and two of the right, the exact 
relation of the epilepsy and hemiplegia being unknown at this time. 
One case of epilepsy is purely nocturnal and several others prac- 
tically nocturnal, though they occasionally suffer a convulsion dur- 
ing the day. One epileptic has his convulsions serially, averaging 
18 to 20 every third week, and another averages 40 to 50 con- 
vulsions monthly in spite of fairly large doses of triple bromides. 

Congenital imbeciles present nothing startling, except that all 
are of very low intelligence. 

The only striking symptom among alcoholic cases seems to be 
active homicidal impulses which were present in each of the six 
cases, one man having actually killed several persons, another 
shooting at some strangers passing his farm, another attempting 
an assault with an ax, a female threatening to kill her family by 
•' chopping oft" their heads," another by assaulting those around 
with whatever she could lay her hands on, and the sixth by vicious 
assaults without warning at every opiwrtunity. Otherwise their 
symptoms did not differ materially from those occurring in the 
white alcoholics. Five or six are dementing types and the sixth 
is a case of chronic alcoholic hallucinosis. 

Senile psychoses present no differences from corresponding 
psychoses in the white race. 



INSANE INDIANS IN SOUTH DAKOTA 391 

Hebephrenics have the same eccentricities, vague, suspicious 
self-centering, distrustfulness, emotional outbursts of superficial 
character, occasional self-complacency, lack of initiative, somato- 
psychic delusions, hallucinations, mostly of an elementary char- 
acter, apathy, silly smiles, impulsivity, irrelevant replies, nega- 
tivism, stereotypies of speech and attitude, " word salad '' and 
automatism. 

Catatonic cases show alternating periods of depression and 
excitement, stupor, motor disturbances, mutism, negativism, 
stereotypies of speech and action, cerea fiexibilitas, psycho-motor 
retardation, apathy, lack of interest, embarrassment, impulsivity, 
destructiveness, hallucinations, delusions and aggressiveness. Our 
dementia prgecox (paranoid form) present dementia, fixed sys- 
temized delusions of a bizarre nature, fantastic hallucinations, 
controlling the actions of the patients, defective memory, hyp- 
ochondriacal ideas, occasional impulsive acts or mannerisms, ver- 
bigeration, and automatism. 

A true paranoiac is extremely interesting, having been abroad 
and demanded that the throne of Denmark be vacated in her 
favor. 

In general, then, Indians present practically the same mental 
symptoms as corresponding forms of mental disease among the 
whites. They are more suspicious, at least until their confidence 
is gained, much more reticent and their superstitions are fully as 
prominent as those of the plantation negro. They are probably 
more destructive and decidedly filthier than the white insane. 
They give little trouble by their attempts to escape, there having 
been no escape from this institution in two and a half years. There 
seems little danger of suicide, though one case has made repeated 
abortive attempts at self-destruction, always by hanging. 

Diagnosis. — It is harder to diagnose the mental condition of the 
insane Indian because of his reticence, suspiciousness, supersti- 
tions, etc., and from the fact that oftentimes the only medium of 
conversation is the sign language, which is very crude. 

Prognosis. — Out of 126 admissions there have been 41 deaths, 
16 recoveries, 9 improvements or unimprovements. 2 escapes and 
58 remain, all of whom are chronically insane. 

Treatment. — Custodial care and attention, together with encour- 
agement and suggestion, regulation of hours for rest, eating. 



392 INSTITUTIONAL CARE OF THE INSANE 

exercise and recreation, careful attention to diet and strict enforce- 
ment of the laws of health and sanitation, constitute the routine 
measures. Epileptics are given a routine treatment of the triple 
bromides and such other sedatives as are required. Seldom is it 
necessary to resort to hypnotics, although an occasional hot bath 
is found to be beneficial. Games of all sorts are encouraged, 
such as baseball, horseshoes, fishing, trapping, croquet and ath- 
letics of all sorts ; also such indoor recreation as checkers, cards, 
dominoes, basket-work, rafiia-work, bead-work and fancy sewing. 
Physical labor for those capable of performing it is aided and 
abetted to the fullest extent. Trips to town and the near-by river 
assist in breaking the monotony. Weekly congregations for the 
singing of sacred music are beneficial. 



IV. 

THE CHINESE AND JAPANESE INSANE IN THE 
UNITED STATES. 

In the nth census of the United States, as of the year 1890, the 
total number of Chinese insane reported was 196. This was a ratio 
of 182 per 100,000 of the Chinese population living in the United 
States on June i, 1890. Of the 196 Chinese insane, 188 were males 
and 8 were females. The proportion of insane among the Chinese 
is small, when it is taken into consideration that the Chinese popu- 
lation consists mainly of adults. 

The total number of Japanese insane reported in 1890 was 3, 
all males. 

The census report for 1910 does not give the Chinese and 
Japanese separate enumeration, but reports, out of a total of 
187,791 insane enumerated of " other colored " races, 491 persons, 
" mostly, if not entirely, Chinese and Japanese."^ 

APPENDIX. 

From a "Narrative of the Adventures and Sufferings of John R. 
Jewitt. Only Survivor of the Crew of the Ship Boston, During a 
Captivity of Nearly Three Years Among the Savages of Nootka 
Sound." 

Tootoosch, his father, was esteemed the first warrior of the tribe, and 
was one who had been particularly active in the destruction of our ship, 
having killed two of our poor comrades, who were ashore, whose names 
were Hall and Wood. About the time of our removal to Tashees, while 
in the enjoyment of the highest health, he was suddenly seized with a fit 
of delirium, in which he fancied that he saw the ghosts of those two men 
constantly standing by him, and threatening him, so that he would take 
no food, except what was forced into his mouth. A short time before this 
he had lost a daughter of about fifteen years of age, which afifiicted him 
greatly, and whether his insanity, a disorder very uncommon among these 
savages, no instance of the kind having occurred within the memory of 
the oldest man amongst them, proceeded from this cause, or that it was 

* " Insane in Hospitals, etc." Bureau of the Census, Washington, D. C, 
1914, page 25. 

32 



394 INSTITUTIONAL CARE OF THE INSANE 

the special interposition of an all-merciful God in our favor, who, by this 
means, thought proper to induce these barbarians still further to respect 
our lives, or that, for hidden purposes, the Supreme Disposer of Events 
sometimes permits the spirits of the dead to revisit the world and haunt 
the murderer, I know not, but his mind from this period until his death, 
which took place but a few weeks after that of his son, was incessantly 
occupied with the images of the men whom he had killed. 

This circumstance made much impression upon the tribe, particularly 
the chiefs, whose uniform opposition to putting us to death, at the various 
councils that were held on our account, I could not but in part attribute to 
this cause, and Maquina used frequently, in speaking of Tootoosch's 
sickness, to express much satisfaction that his hands had not been stained 
with the blood of any of our men. 

When Maquina was first informed by his sister of the strange conduct 
of her husband, he immediately went to his house, taking us with him, 
suspecting that his disease had been caused by us, and that the ghosts of 
our countrymen had been called thither by us to torment him. We 
found him raving about Hall and Wood, saying that they were " peshak," 
that is, bad. Maquina then placed some provision before him, to see if he 
would eat. On perceiving it, he put forth his hand to take some, but 
instantly withdrew it with signs of horror, saying that Hall and Wood 
were there, and would not let him eat. Maquina then pointing to us, 
asked if it was not John and Thompson that troubled him. " Wik," he 
replied, that is, no. John " klushish " — Thompson " klushish " — John and 
Thompson are both good ; then turning to me, and patting me on the 
shoulder, he made signs for me to eat. I tried to persuade him that Hall 
and Wood were not there, and that none were near him but ourselves ; he 
said, " I know very well that you do not see them, but I do." 

At first, Maquina endeavored to convince him that he saw nothing, and 
to laugh him out of his belief ; but finding that all was of no purpose, he at 
length became serious, and asked me if I had ever seen anyone affected 
in this manner, and what was the matter with him. I gave him to under- 
stand, pointing to his head, that his brain was injured, and that he did not 
see things as formerly. 

Being convinced by Tootoosch's conduct that we had no agency in his 
indisposition, on our return home Maquina asked me what was done in 
our country in similar cases. I told him that such persons were closely 
confined, and sometimes tied up and whipped, in order to make them 
better. After pondering for some time, he said that he should be glad 
to do anything to relieve him, and that he should be whipped, and imme- 
diately gave orders to some of his men to go to Tootoosch's house, bind 
him and bring him to his, in order to undergo the operation. Thompson 
was the person selected to administer this remedy, which he undertook 
very readily ; and for that purpose provided himself with a goodly number 
of spruce branches, with which he whipped him most severely, laying it 
on with the best will imaginable, while Tootoosch displayed the greatest 
rage, kicking, spitting, and attempting to bite all who came near him. 



CHINESE AND JAPANESE INSANE IN THE UNITED STATES 395 

This was too much for Maquina, who, at length, unable to endure it longer, 
ordered Thompson to desist, and Tootoosch to be carried back, saying 
that, if there was no other way of curing him but by whipping, he must 
remain mad. 

The application of the whip produced no beneficial effect on Tootoosch, 
for he afterwards became still more deranged; in his fits of fury some- 
times seizing a club, and beating his slave in a most dreadful manner, and 
striking and spitting at all who came near him, till, at length, his wife, no 
longer daring to remain in the house with him, came with her son to 
Maquina's. 



CHAPTER XII 

INSTITUTIONAL POPULATION OF THE 
INSANE AND FEEBLE-MINDED 

CENSUS OF THE INSANE 



INSTITUTIONAL POPULATION. 

The number of patients cared for in the earHer estabhshed hos- 
pitals for the insane was strictly limited. This was in a great 
measure due to the fact that the hospitals were designed for a 
class of patients " furiously mad " or " dangerous to be at large/' 
and that the idea of insanity as a disease, capable of cure, was 
unthought of. The measure of care meted out to these unfor- 
tunates was of a custodial character only, and such " maniacs " as 
were admitted were only too likely to end their days in the asylum. 
Thus we find that the number of patients admitted at Williams- 
burg, the Pennsylvania Hospital and Bloomingdale Asylum in the 
earlier days of their existence manifestly constituted but a small 
proportion of the insane then existing in the localities ministered 
to by those hospitals. The fact that the care of insane dependents 
was a local matter, and the reluctance of county boards and town- 
ship organizations to assume the financial burden which placing 
the indigent insane in hospitals would entail, alone were sufficient 
to limit strictly the number sent to the early hospitals. 

In this respect the figures upon page 400, showing the admissions 
to the Hartford Retreat, which, although an asylum of a semi- 
private class, had an arrangement with the towns of Connecticut, 
and received patients at a rate of payment less than the actual 
cost of treatment, are of interest. 

The figures given are for the period 1824-1856, since which date, 
owing to the establishment of other institutions, the number of 
admissions has increased but slowly. 

At the New York Hospital, now the Bloomingdale Hospital, 
the total number of insane received previously to December 31, 
1803, was only 215. 

At the time of the opening of the new Bloomingdale Asylum in 
182 1 there were but four other public institutions exclusively 
devoted to the insane in the United States. By 1844 16 new asy- 
lums were in operation, making the total number in the country 
21. In 1849 the total number of insane patients cared for in insti- 
tutions, both public and private, in New York State was less than 
1200. 



400 



INSTITUTIONAL CARE OF TPIE INSANE 



OPERATIONS OF THE RETREAT FROM THE BEGINNING 
OF EACH YEAR. 









Discharged. 


Daily 


Year. 




Recovered. 


Improved. 


Stationary. 


Died. 


number. 






V 



H 




"a 

a 


"a 

H 


6 
"a 


V 

H 
B 

V 







B 







B 

V 




H 


Total. 


1824-5 






44 
33 
37 
40 
42 

51 
53 
80 
68 
72 

72 
73 
91 
67 
94 

84 
67 
96 
83 
80 
105 
128 

III 
93 
133 
135 
128 

158 
140 
177 
169 
157 






10 
16 

24 
27 
26 

28 
32 
46 

37 
43 

36 
42 

55 
42 

49 

50 
38 
56 

45 
44 
45 
60 

56 
40 
70 
64 
59 

68 
64 
64 

73 
59 


















I 
I 





1825-6 




















1826-7 




















1827-8 


















4! . 


1828-9 






















2 





1829-30 




















I 830- I 


















I: 


1831-2 


















6 : 


1832-3 


















41 


1833-4 


















31 


1834-5 


















6 


1835-6 


















6 

6 

10 

8 

2 

9 

8 

7 

9 

II 

16 

II 
12 
12 
30 
15 

22 
21 
22 

17 
26 




1836-7 




























1837-8 




















1838-9 




















1839-40 




















I 840- I 




















1841-2 
1842-3 


45 
50 
51 
56 
56 

50 
39 
49 
60 
56 

68 
66 
74 
69 
70 


51 

33 
29 

49 

72 

61 
54 
84 
75 
72 

90 

74 
103 
100 

87 


27 
26 
26 

23 
24 

16 

12 
20 
17 

25 

26 
32 
22 
26 
18 


29 

19 
18 
22 
36 

40 
28 
50 

47 
34 

42 
32 
42 
47 
41 


6 
II 
26 
13 
17 

22 

13 

8 

II 

15 

10 
18 
16 
20 
17 


10 

13 
17 

7 
15 

13 
II 
15 
13 
II 

12 
22 

26 
18 
28 


16 

24 

43 
20 
32 

35 
24 

23 
24 
26 

22 
40 
42 
38 

45 


6 


3 


9 


6 
4 

5 
7 
5 

8 
4 
7 

17 
9 

9 
10 

13 

9 

12 


2 

3 

4 

4 

II 

3 
8 
5 

13 
6 

13 
II 

9 
8 

14 




1843-4 








84 


1844-5 
1845-6 

1846-7 
1847-8 
1848-9 
1849-50 
I 850-1 

185 1-2 
1852-3 
1853-4 
1854-5 
1855-6 


7 
9 

I 

7 
12 

3 
8 

7 
13 
14 
18 
10 


2 
3 

6 
6 
5 
4 
6 

15 
13 
19 
16 

13 


9 
12 

7 
13 
17 

7 
14 

22 
26 
33 
34 
23 


97 
121 

127 
127 
141 
143 
iSi 

168 
179 
180 
185 
187 



Two years later the Association of Medical Superintendents of 
American Institutions for the Insane, at their sixth annual meet- 
ing, held in Philadelphia, May 19, 185 1, adopted a series of " Prop- 
ositions"^ which were formulated for the construction of hos- 



' See "The Propositions," page 217. 



INSTITUTIONAL POPULATION 4OI 

pitals for the insane. One section provided that not more than 
250, and preferably 200, patients should be placed in one buildin.i^. 
This limitation of capacity of proposed hospitals was extended to 
a permissible accommodation of 600 in 1866. This limitation was 
speedily passed, however, the need of care for insane patients in 
rapidly growing states becoming so great that before many years 
had passed many institutions were already caring for from 1000 to 
1200 patients. The first notable departure from the " Proposi- 
tions " was at Willard, N. Y., where provision was made for 
accommodations for 2000 patients of the chronic class. They 
were housed in a series of block buildings with a central or admin- 
istration building. This method of construction was followed by 
the adoption of the " cottage plan," the first example of which was 
established at Kankakee, 111., in 1877. The result of this method 
of construction has been practically to remove all restrictions as 
to the number of insane patients to be cared for in any one hos- 
pital, and we now have hospitals with populations of patients and 
employees of 3000, 4000 and even larger. 

The following table showing the population in the various 
public and private hospitals within the United States as of January 
I, 19 10, has been compiled from the Insane and Feeble-minded in 
Institutions, 1910, Bureau of the Census.^ 

These are the latest available figures showing the number of 
insane in the hospitals within the United States at any one date. 
Since the date of this enumeration the population of many of the 
hospitals as given has increased largely. There have been also 
many additional hospitals established. The names of the various 
hospitals are given as of January i, 1910, although since that date 
many of the states have changed the titles of their institutions. 

p Kiv. ALABAMA, 

rublic : 

The Bryce Hospital 1.429 

The Mount Vernon Hospital 610 



Total 2,039 

jj^. ARIZONA. 

Territorial Asylum for the Insane 337 



^ Washington, Government Printing Office, 1914. 



402 INSTITUTIONAL CARE OF THE INSANE 

„ ... ARKANSAS. 

Public : 

State Hospital for Nervous Diseases 1,092 

n , ,• CALIFORNIA. 

Public : 

Agnew State Hospital 698 

Mendocino State Hospital 856 

Napa State Hospital 1,841 

Southern California State Hospital 1,270 

Stockton State Hospital 1,895 

Private 92 

Total 6,652 

Public: COLORADO. 

Colorado State Insane Asylum 882 

Denver City and County Hospital 128 

Private 189 

Total 1,199 

^ ,,. CONNECTICUT. 

Public : 

Connecticut Hospital for the Insane 2,436 

Norwich Hospital for the Insane 623 

Private : 

Hartford Retreat 156 

Other institutions 364 

Total 3,579 

^ ,,. DELAWARE. 

Public: 

Delaware State Hospital 44i 

-r, , ,• DISTRICT OF COLUMBIA. 

Public : 

Government Hospital for the Insane 2,890 

Public: FLORIDA. 

Florida Hospital for the Insane 849 

T3 , ,. GEORGIA. 

Public : 

Georgia State Sanitarium 3.082 

Private : 

Allen's Invalid Home 50 

Total 3,132 



INSTITUTIONAL POPULATION 403 

Public: IDAHO. 

The Idaho Insane Asylum 259 

The Northern Idaho Insane Asylum 129 

Total 388 

Public: ILLINOIS. 

Anna State Hospital 1,478 

Chester State Hospital 215 

Elgin State Hospital 1,384 

Jacksonville State Hospital 1,440 

Kankakee State Hospital 2,549 

Peoria State Hospital 2,107 

Watertown State Hospital 1,412 

Cook County Hospital for Insane 2.174 

Madison County Poor Farm 4 

Private 76 

Total 12,839 

Public: INDIANA. 

Central Indiana Hospital for Insane 1,815 

Eastern Indiana Hospital for Insane 795 

Northern Hospital for Insane 978 

Southern Indiana Hospital for Insane 724 

Marion County Asylum for Insane 189 

Private 26 

Total 4.527 

Public: lO^VA- 

Cherokee State Hospital 887 

Clarinda State Hospital 1,054 

Independence State Hospital 1,161 

Mount Pleasant State Hospital 1,020 

County asylums 642 

Private : 

Mercy Hospital, Davenport 156 

St. Bernard's Hospital, Council Bluffs 209 

St. Joseph's Sanitarium, Dubuque 230 

The Retreat, Des Moines 18 

Total 5.377 



404 INSTITUTIONAL CARE OF THE INSANE 

Public: KANSAS. 

Hospital for Epileptics 303 

Osawatomie State Hospital 1,294 

Topeka State Hospital 1,215 

Private 100 

Total 2,912 

Public: KENTUCKY. 

Central Kentuckj- Asylum for the Insane 1-352 

Eastern Kentucky Asylum for the Insane 1,063 

Western Kentucky Asylum for the Insane 1,072 

Private 51 

Total 3,538 

Public: LOUISIANA. 

East Louisiana Hospital for the Insane 1,362 

Louisiana Hospital for Insane 553 

Private : 

Louisiana Retreat, New Orleans 243 

Total 2,158 

Public: M'^INE. 

Eastern Maine Insane Hospital 347 

Maine Insane Hospital 91 1 

Total 1,258 

p , ,■ MARYLAND. 

Public : 

Maryland Hospital for the Insane 586 

Springfield State Hospital 946 

Bay View Hospital 438 

County asylums 354 

Private : 

Mount Hope Retreat 623 

The Sheppard and Enoch Pratt Hospital 102 

Other institutions 171 

Total 3,220 



IXSTITUTIONAL POPULATION 405 

p^^jj^. MASSACHUSETTS. 

Bdston State Hospital -J"' 

Bridgewater State Hospital 657 

Danvers State Hospital 1,391 

Medfield Insane Asylum 1,604 

Monson State Hospital 2t2>i 

Northampton State Hospital 839 

State Colony for the Insane, Gardner 586 

State Infirmary, Tewksbury 711 

Taunton State Hospital 970 

Westborough Insane Hospital 978 

Worcester State Asylum 1,148 

Worcester State Hospital 1,316 

Private : 

McLean Hospital 224 

Other institutions 67 

Total 11.601 

Public: MICHIGAN. 

Eastern Michigan Asylum i .343 

Michigan Asylum for the Insane 1,900 

Northern Michigan Asylum 1,396 

State Asylum, Ionia 408 

State Psychopathic Hospital 41 

Upper Peninsula Hospital for the Insane 758 

Wayne County Asylum 535 

Private : 

St. Joseph's Retreat. Dearborn 259 

Other institutions 59 

Total 6.699 

Public: MINNESOTA. 

Anoka State Asylum 479 

Fergus Falls State Hospital 1.574 

Hastings State Asylum 478 

Rochester State Hospital 1,201 

St. Peter State Hospital 1.005 

Private 7 



Total 4.744 



406 INSTITUTIONAL CARE OF THE INSANE 

Public: MISSISSIPPI. 

East Mississippi Insane Hospital 536 

State Insane Hospital 1,442 

Total 1,978 

Public: MISSOURI. 

State Hospital No. i 1,104 

State Hospital No. 2 1,341 

State Hospital No. 3 1,191 

State Hospital No. 4 586 

St. Louis City Insane Asylum 693 

St. Louis Poorhouse TZI 

County asylums 30 

Private : 

St. Vincent's Institution, St. Louis 301 

Other institutions 185 

Total 6,168 

Public: MONTANA. 

Montana State Hospital for the Insane 697 



p • ^, . NEBRASKA. 

Private : 

Nebraska Hospital for the Insane 569 

Nebraska State Hospital 1,146 

Norfolk State Hospital 275 

Total 1,990 



Public: NEVADA. 

Nevada Hospital for Mental Diseases 230 

Putjljj,. NEW HAMPSHIRE. 

New Hampshire State Hospital 876 

Rockingham County Farm 28 

Private 5 

Total 909 



INSTITUTIONAL POPULATION 407 

Public: NEW JERSEY. 

New Jersey State Hospital, Morris Plains 2,056 

New Jersey State Hospital, Trenton i,342 

Essex County Hospital for the Insane 1,277 

Hudson County Hospital for the Insane 668 

Other county hospitals 686 

Private 13 

Total 6,042 

public: NEW MEXICO. 

New Mexico Insane Asylum 219 

o uv NEW YORK. 

Public : 

Binghamton State Hospital 2,282 

Buffalo State Hospital 1,912 

Central Islip State Hospital 3i994 

Dannemora State Hospital 369 

Gowanda State Homeopathic Hospital 995 

Hudson River State Hospital 2,937 

Kings Park State Hospital 3.1 17 

Long Island State Hospital 764 

Manhattan State Hospital 4.400 

Matteawan State Hospital 763 

Middletown State Homeopathic Hospital 1,764 

Rochester State Hospital 1,320 

St. Lawrence State Hospital 1,844 

Utica State Hospital 1,369 

Willard State Hospital 2,321 

Private : 

Bloomingdale Hospital for Insane 337 

Other institutions 792 

Total 31,280 

public: NORTH CAROLINA. 

State Hospital, Goldsboro 668 

State Hospital, Morganton i,i93 

State Hospital, Dix Hill 578 

State Hospital for Dangerous Insane 50 

Private 33 

Total 2,522 



408 IXSTITUTIONAL CARE OF THE INSANE 

Public : NORTH DAKOTA. 

State Hospital for Insane 628 

Public: OHIO- 

Athens State Hospital 1,336 

Cleveland State Hospital i,447 

Columbus State Hospital i,743 

Dayton State Hospital 1,195 

Longview Hospital 1,284 

Massillon State Hospital i,S7i 

Toledo State Hospital 1,796 

Private : 

Cincinnati Sanitarium 82 

Other institutions 140 

Total 10,594 

Public: OKLAHOMA. 

Oklahoma Hospital for the Insane, Supply 471 

Private : 

The Duke Sanitarium 11 

Oklahoma Hospital for the Insane, Norman 628 

Total 1,110 

Public: OREGON. 

Oregon State Insane Asylum, Salem 1,565 

Pybii^, . PENNSYLVANIA. 

The Dixmont Hospital 975 

Pennsylvania State Lunatic Hospital 1,169 

State Asylum for Chronic Insane 851 

State Hospital for Insane, Danville 1,486 

State Hospital for Insane (men) , Norristown 1,305 

State Hospital for Insane (wromen), Norristown 1,441 

State Hospital for the Insane, Warren 1,329 

Allegheny County Hospital for the Insane 652 

Blair County Hospital for the Insane 207 

Chester County Hospital for Insane 266 

Cumberland County Hospital for Insane 87 

Hillside Home 441 

Lancaster County Hospital 259 

Luzerne County Hospital for Insane 589 



INSTITUTIONAL POPULATION 4O9 

Potter County Home and Asylum 36 

Somerset County Home and Hospital 100 

Schuylkill County Almshouse in 

Philadelphia Hospital for Insane 2,174 

Pittsburgh City Home and Hospital 597 

Pittsburgh North Side City Home 212 

Private : 

Friends Asylum 171 

Pennsylvania Hospital for the Insane 434 

Other institutions 166 

Total 15,058 

p ,,. RHODE ISLAND, 

rublic : 

State Hospital for the Insane 1,101 

Private : 

Butler Hospital 142 

Total 1,243 

p^^^,j^.. SOUTH CAROLINA. 

State Hospital for the Insane 1,541 

Public: SOUTH DAKOTA. 

Asylum for Insane Indians 60 

South Dakota State Hospital 804 

Total 864 

p ,,. TENNESSEE. 

Public : 

Central Hospital for Insane 642 

Eastern Hospital for Insane 515 

Western Hospital for Insane 67p 

County asylums 368 

Total 2. 195 

p Ki- TEXAS. 

Public ; 

North Texas Hospital for Insane 1,851 

Southwestern Insane Asylum 757 

State Lunatic Asylum 1.377 

Private 68 

Total 4.053 



410 INSTITUTIONAL CARE OF THE INSANE 

_,,,. UTAH. 

Public : 

State Mental Hospital 342 

VERMONT. 
Public : 

Vermont State Hospital for the Insane 572 

Private : 

Brattleboro Retreat 4°^ 

Lakeview Sanitarium, Burlington i6 

Total 990 

VIRGINIA. 
Public : 

Central State Hospital '-340 

Eastern State Hospital 674 

Southwestern State Hospital 580 

Western State Hospital 1.041 

Total 3,635 

WASHINGTON. 
Public : 

Eastern Washington Hospital for Insane 696 

Western Washington Hospital for Insane 1,291 

Total 1.987 

WEST VIRGINIA. 
Public : 

Second Hospital for Insane 505 

West Virginia Asylum 235 

West Virginia Hospital for Insane 982 

Total ^^^^^ 

WISCONSIN. 
Public : 

Northern Hospital for the Insane 635 

The State Hospital for the Insane 621 

County asylums 5, 180 

Private ^5i 

Total 6,587 

WYOMING. 
Public : 

Wyoming State Hospital for the Insane 162 



II. 

CENSUS OF THE INSANE. 

Prior to the United States census of 1840 no enumeration was 
attempted by the federal government of the insane residing in the 
different states. The census for that year, however, has a distinct 
enumeration, under the heading, " Insane and Idiots," and further 
divided into " white " and " colored and slaves." 

In the sixth report of the Prison Discipline Society of ]Massa- 
chusetts, page 64, it is stated that : 

" By a late report to the Legislature it appears that there were in 
1825, in the State of New York, 819 lunatics; 1421 idiots; total 
2240; or one to every 721 souls. Of the lunatics only 263 were 
able to pay for their support ; the other 556 lunatics were insane 
paupers, either confined in private families, poorhouses or jails, or 
roaming at large.*' 

In the eighth report of the Prison Discipline Society for 1833, 
page 24, it is stated : 

"We estimate the number of lunatics as i to 1000 of the whole 
population, or the whole number of lunatics in the United States 
at 12,000. We estimate the proportion of this class of persons in 
prisons, houses of correction and almshouses at one-fifth part of 
the whole number, or 2400." 

In the ninth report of the Prison Discipline Society, 1833, page 
85, referring to an investigation that had been made the previous 
year as to the number of insane then residing in the State of New 
Hampshire, the following statement is made : 

" When the examination was made, one year after, and from the 
official returns, the committee were prepared to submit their report. 
They made the following statement : 

"The number of insane, as returned to the Governor, is 201, 
more than half of whom are supported as paupers. From many 
towns no returns have been received ; from others, the accounts 
are erroneous, there being cases known to the committee which 
escaped the notice of the selectmen. The actual number of insane, 
therefore, is much larger than appears by the documents submitted 
bv the committee." 



412 INSTITUTIONAL CARE OF THE INSANE 

The report further states that the above statement is sufficient 
foundation for the estimate that the lunatics in the I'nited States 
are nearly as i to looo of the population ; or as follows: 

Maine 399 South Carolina 516 

New Hampshire 269 Kentucky 687 

Vermont 280 Tennessee 681 

Massachusetts 610 Ohio 935 

Rhode Island 97 Louisiana 215 

Connecticut 297 Indiana 139 

New York 1,918 Illinois 157 

New Jersey 320 Alabama 309 

Pennsylvania 1,348 Missouri 140 

Delaware 76 Michigan 31 

Maryland 447 Arkansas 30 

Virginia 1,211 Florida 35 

North Carolina "jy] District of Columbia 39 



11,923 

This list contains no return from Georgia, the population of 
which was, in 1832, 516,832; nor Mississippi with 136,621. 

The population of the United States, as appears from a letter 
of the Secretary of State to the Speaker of the House of Repre- 
sentatives, dated January 4, 1832, was not exactly ascertained at 
the fifth census. The returns for the territories of Florida, Arkan- 
sas and Michigan and the District of Columbia were wanting. Mr. 
W. Gore Ousely, in his '* Remarks on the Statistics and Political 
Institutions of the United States," says (p. 197) that "the whole 
population of the United States probably amounts at present 
(1832) to as nearly as possible 13,000,000." 

In the i6th report of the Prison Discipline Society, 1841. page 
12, occurs the following: 

" Dr. Hrigham says. ' In the year 1835 there were received in 
three of the institutions in .Massachusetts, from that state alone, 
124 patients, who became crazy that year.' This number is esti- 
mated by the same author to be probably not more than half who 
became insane in the same state, during the same period. If this 
statement and opinion be made the basis of an estimate, it will give 
as the number who l)ecome insane annually in the United States 

5719-" 

According to the United States census of 1840 the number of 
insane and idiots was i to 990 of population. The following table 
shows the figures by states : 



CENSUS OF THE INSANE 



413 



INSANE AND IDIOTS. 

White Colored and Slaves 

Public Private Public Private 

Total Population. Charge. Charge. Charge. Charpe. 

Maine 50i,793 207 330 38 56 

New Hampshire 284,574 180 306 11 8 

Massachusetts 737.699 47i 600 173 2"] 

Rhode Island 108,830 117 86 58 

Connecticut 309,978 1 14 384 24 20 

Vermont 291,948 144 254 4 9 

New York 2,428,921 683 1,463 56 138 

New Jersey 373-3o6 144 225 27 46 

Pennsylvania 1,724,033 469 1-477 55 132 

Delaware 78,085 22 30 7 21 

Maryland 469,232 I33 254 42 99 

Virginia 1,239,797 3i7 IZ^ 58 326 

North Carolina 753,419 152 428 29 192 

South Carolina 594,398 91 285 16 121 

Georgia 691,392 51 243 26 108 

Alabama 590,756 39 I93 25 100 

Mississippi 375,651 I4 102 16 66 

Louisiana 352,411 6 49 7 38 

Tennessee 829,210 103 596 28 124 

Kentucky 779,828 305 490 48 132 

Ohio 1,519,467 363 832 62 103 

Indiana 685,866 no m 28 47 

Illinois 476,183 36 177 14 65 

Missouri 383,702 42 160 18 50 

Arkansas 97,574 9 36 813 

Michigan 212,267 2 37 5 21 

Florida 54,477 i 9 12 

Wisconsin 30,945 17 03 

Iowa 43,112 25 04 

District of Columbia. 43.712 i 13 34 

Total 17,062,566 4,329 10,179 833 2,093 

Concerning the correctness of the census figures of 1840 as 
given above Dr. E. Jarvis states : ^ " The American Statistical 
Society, in 1845, first analyzed the census of 1840, and then pre- 
pared a long memorial to Congress. In their petition they set forth 

the errors, inconsistencies, contradictions and falsehoods of that 

document, and asked Congress to disavow the whole, and cause 

another and correct one to be prepared and published. This 

^ Journal of Insanity, Vol. 8, p. 269. 



414 INSTITUTIONAL CARE OF THE INSANE 

memorial was presented to both houses of Congress, and referred 
to separate committees in each. . . . These errors of state- 
ment seem to be the greatest in regard to the insanity of the colored 
population of the Northern states. Fortunately, besides the dis- 
agreements of the several copies of the reports with each other, 
the document itself furnishes its own refutation. One statement 
contradicts another statement and shows its error." 

It can be safely stated that the fifth census of 1840 is absolutely 
worthless as regards any correct enumeration of cases of insanity 
and idiocy. 

In the 20th report of the Prison Discipline Society for 1845, 
page 7, it is stated that : 

'' In the United States there are 20,000 lunatics. In 18 states 
and 26 asylums provision has been made for about 4125 lunatics." 

At each general decennial census of the population from 1850 to 
1890, inclusive, the attempt was made to secure a complete enu- 
meration of the insane by inserting on the general population 
schedule a question as to insanity. The question in the form in 
which it appeared specified insanity as one of a number of defects 
which were to be reported wherever found to exist. In 1850 and 
in i860 the question read " whether deaf and dumb, blind, insane, 
idiotic, pauper or convict." And in 1870 it was the same, with the 
omission of " pauper or convict." In 1880, however, insanity and 
each of the other defects specified were covered by a separate 
question ; but in 1890 the question again became general and com- 
prehensive — " whether defective in mind, sight, deformed, with 
name of defect.'" 

Previous to 1880 the census enumeration of the insane in the 
United States was more or less incomplete. Indeed, the resulting 
statistics have been characterized as " entirely worthless so far as 
the calculation of ratios of number of insane to population is con- 
cerned, since the number of insane returned in these censuses was 
certainly less than half the number actually present.'" 

At the tenth census, 1880, the returns of the enumerators were 
supplemented by special schedules filled out by physicians, who 
reported about 17 per cent of the total number of insane accounted 

' " Insane and F"eeble-minded in Institutions, 1910," Bureau of Census, 
Washington, D. C, 1914, p. li. 
"Report on the insane, etc., Eleventh Census, 1890, p. 7. 



CENSUS OF THE INSANE 



415 



for in that year. The co-operation rendered by medical practi- 
tioners was much less in some states than in others, and resulted 
in certain instances in misleading ratios. This method of enu- 
meration was not pursued in the nth census, taken in 1890, but the 
population enumerators counted as before all of the insane com- 
ing within their knowledge, whether found in or outside of 
institutions.' 

The attempt to secure a complete enumeration of the insane in 
connection with the general population census was not repeated at 
the twelfth census, which was taken in 1900. Instead there was a 
special census of the insane taken in 1904, which, like the succeed- 
ing one in 1910, was restricted to the insane in institutions. The 
postponement of the inquiry, however, involved this disadvantage, 
that it interfered with direct comparisons between the number of 
insane and the general population as classified by race, nativity, 
age, etc. Accordingly the report for 1904 did not show any ratios 
except the ratios of the total number of insane enumerated in 
1904 to the total estimated population for the same year. 

The following table ^ shows the number of insane persons enu- 
merated at each census from 1850 to 1910, those in institutions for 
the insane and outside such institutions being shown separately for 
the censuses of 1880 and 1890: 





Insane enumerated 

in institutions for 

the insane. 


Insane enumerated 
outside such in- 
stitutions. 


Total insane 
enumerated. 


Year. 


Number. 


Per 100,000 
population. 


Number. 


Per 100,000 
population. 


^, , Per 100,000 
Number, population. 


191O 


187.791 

150,151 

74,028 

40,942 

t 


204.2 

183.6 

118. 2 

81.06 

.... 


* 
* 

32.457 
51,017 

t 
t 
t 


* 
* 

51.8 
IOI.7 


187,791 204.2 
150,151 183.6 
106,485 170.0 
91,959 183-3 
$37,432 $97.1 
1 24,042 ±76.5 
$15,610 $67.3 


I 004 . . 


1890 


1880 


1870 


i860 

1850 


t 
t 



* No enumeration of insane outside of institutions. 

t Included in the enumeration, but not returned separately. 

; Enumeration believed to have been seriously deficient. 



' Special reports, insane and feeble-minded in hospitals and institutions. 
1904, Bureau of Census, John Koren, expert special agent, p. 3. 

^This table is taken from "Insane and Feeble-minded in Institutions, 
1910," p. 12, Bureau of Census, Washington, D. C, 1914. 



4l6 INSTITUTIONAL CARE OF THE INSANE 

It is not to be supposed that the very marked increase in the 
number of insane reported in 1880 as compared with the preced- 
ing census measures an increase in the actual amount of insanity. 
It can only be accounted for by the improvement in the efficiency 
of the canvass in 1880, as already noted. 

In 1890 there was no sujiplementary canvass through the agency 
of physicians as in 1880. At the census of 1880, 183.3 insane per- 
sons were reported for each 100,000 inhabitants, but in 1890 the 
ratio fell to 170 per 100,000. It is safe to say that this decline in 
the ratio did not represent an actual decline in insanity, but, as 
stated in the report of 1890, is attributable to the difference in the 
completeness of the enumeration.^ 

As already noted, the census of 1890 was the last one at which 
the attempt was made to secure a complete enumeration of the 
insane, the census of 1904 and 1910 being confined to the insane 
in institutions. At the censuses prior to 1880, on the other hand, 
the number of insane in institutions or hospitals for this class of 
the population was not reported separately, so that comparisons 
of the growth of this class of the insane population can be made 
only for the thirty-year period, 1880- 1910. Of the total insane 
population enumerated in 1880, 40,942 were reported as in insti- 
tutions or hospitals, representing a ratio of 81.6 per 100,000 popu- 
lation ; by 19 10 the number in institutions had increased to 187,791, 
a ratio of 204.2 per 100,000 population.^ 

It is not probable that the enumeration of inmates of special 
institutions for the insane has been greatly defective at any 
census.^ 

In 1880 the ratio of the insane was 183.3 per 100,000 of the 
population. In 19 10, as already noted, the insane in hospitals alone 
represented a ratio of 204.3 P^r 100,000 population. 

At the same time it is practically certain that insanity has not 
increased to anything like the extent which a comparison of the 
different census enumerators would indicate. The extension of 
the practice of jilacing the insane imder institutional care has had a 
very great influence upon statistics. 

Other influences have likewise contributed to the apparent 
increase of insanity, or to the increase in the number of recognized 

' " Insane in Hospitals, etc." Bureau of Census, 1914, p. 13. 
' Ibid. ' Ibid. 



CENSUS OF THE INSANE 417 

and recorded cases. Among these may be mentioned : Increasing 
average length of hfe, bringing more people to the " insanity age " 
periods ; advances in diagnostic methods in psychiatry, leading to 
detection of mental factors in physical cases ; the establishment of 
dispensaries ; the provision of " voluntary " and emergency com- 
mitment ; and better means of transportation, making it possible to 
bring to the hospital cases in poor physical condition.' 

The appended Table A gives the enumeration by states of the 
total number of insane at each census from 1850 to 1890 inclusive, 
with the ratio per 100,000 of population. 

The appended Table B gives the enumeration by states of the 
insane in hospitals at each census from 1880 to 1890 inclusive, with 
the ratio per 100,000 of population. 

Appendix C is inserted as being of interest in connection with 
the preceding census tables. 

* Ibid., p. 14. 



4i8 



INSTITUTIONAL CARE OF THE INSANE 
APPENDIX A. 



Total Numher of Insane Enumerated at Each Census from 1850 to 1890, 
AND THE Ratios per 100,000 Population.* 



Total Number. 



United States 

Maine 

New Hampshire. . 

Vermont 

Massachusetts . . . . 

Rhode Island 

Connecticut 

New York 

New Jersey 

Pennsylvania 

Delaware 

Maryland 

Dist. of Columbia 

Virginia 

West Virginia. .. . 
North Carolina. . 
South Carolina. . 

Georgia 

Florida 

Ohio 

Indiana 

Illinois 

Michigan 

Wisconsin 

Minnesota 

Iowa 

Missouri. • ■ 

North Dakota . .. 
South Dakota.. .. 

Nebraska 

Kansas 

Kentucky 

Tennessee 

Alabama 

Mississippi 

Louisiana 

Texas 

Oklahoma 

Arkansas 

Montana 

Wyoming 

Colorado 

New Mexico 

Arizona 

Utah 

Nevada 

Idaho 

Washington . . . . 

Oregon. 

California 



0^0 



1880. 



o c 
q o 



u o 



06,485 170.09 
1,299 196.5 
961 255.2 
823 247.6 

6, 103 276.2 

795 230.1 

2,056 275.5 

17,846 297.5 

3,163 218.9 

8,482 161. 3 

197 116.9 
1,646 157.9 
1,578 684.9 
2,4071145-4 
1,079 141.5 
1,725 ! 106.6 

912 79.2 
1,815 98.8 

351 89.7 
7,600 [207.0 
3,291 1150.1 
6,641 
3.725 



1870. 



11,959 183-337, 
1,542237.6 
1,056304.3 
1,015305.5 
5,127,287.5 
684247.3 
1,723276.7 

[4.055276.5 
2,405 212.6 



3.513 
2,205 

3.197 

3,418 

221 

310 

932 

1,794 

2,729 

1,845 

1,469 

1,104 

910 

1,670 

7 
790 
192 

40 
326 

66 

64 
166 
183 

83 

380 

640 

3,736 



173.6 
177-9 
208.3 
169.4 
167.2 
127.6 
121.0 

94-3 
88.0 

125.7 

146.8 

104.4 

97.1 

85.6 

81.4 

74.7 

11.3 

70.0 

145.3 

65-9 

79.1 

43-0 

107.3 

79.8 

399-9 

98.4 

108.8 

204.0 

309.2 



8,304 
198 

1,857 
938 

2,411 
982 

2,028 

1,1X2 
1,697 
253 
7,286 
3,548 
5.134 
2,796 
2,526 
I. 145 

2,544 
3.310 

§ 

§72 
450 
1 ,000 
2.784 
2,404 
1,521 
1,147 
1,002 

1,564 



2, 



6, 



193-9 
135.0 
198.7 
528.1 

159-4 
158.8 
144.9 
III. 7 

IIO.O 

93.8 
27.8 
179.3 
166.7 
170.8 
192.0 
146.6 
156.6 
152.6 

53-2 
99-5 
100.4 
168.9 
155-9 
120.5 
101.4 
io6.6 
98-3 



a f5 



0.^ 



789 

59 

4 

99 

153 

21 

151 
31 
16 

135 

378 

2,503 



98-3 

150.6 

19.2 

50.9 
127.9 

51.9 
104.9 

49-7 

49.0 

179.7 

216.3 

289.5 



432 
792 
548 
721 
662 
312 
772 
353 
918 

.895 

65 

733 

479 

,125 

374 

779 

333 

634 

29 

,414 

,504 

,652 

814 

846 

302 

742 

,263 

i 

1 3 
28 

131 

,245 
925 
555 
245 
451 
270 



i860. 



97.1 
126.3 
172.2 
218.1 
182.7 
143-5 
143-6 

144-9 

101.3 

110.6 

51-9 

93-9 

363-7 

91-8 

84.6 

72.7 

47.2 

53-5 

15.4 

1 28. 1 

89.5 
64.0 
68.7 
80.2 
68.7 
62.1 

73.4 



24, 



2 "> 



v o 



042 76.5 
704 112.1 



4. 



ti 



506 
693 
105 
288 
331 
317 
589 
760 
60 
560 
204 
179 



155.2 

219.9 

171.0 

164.9 

71.9 

1 1 1.2 

87.6 

95-0 

53-5 

81.5 

271.7 

73.9 



1850. 



660 

317 
491 

25 

,293 

.035 

683 

250 

283 

25 

201 

770 



161 
2 



12 

50 

I 

25 
2 
I 

23 
122 
.146 



21.2 
22.8 
35-9 
94-2 
73-5 
55-6 
29.6 
62.0 
33-0 



66.5 
450 
46.4 
17.8 
98.0 
76.6 
39-9 
33-4 
36- 5 
14-5 
29.8 
65-1 



33.2 
9.7 



30.1 

54-4 

10.4 

28.8 

4.7 

6.7 

96.0 

134.2 

204.5 



5 

10 
623 
640 

257 
272 
169 
125 



87 



28 



15 



3 

23 

456 



17.3 
9-3 
53.9 
57.7 
26.7 

34-4 
23.9 
20.7 



5.610 
561 
378 
560 

1,680 
217 
470 

2,521 

379 

1,914 

68 

546 

23 

t970 



67-3 

96.2 

1 18.9 

178.3 
168.9 
147.0 
126.7 
81.4 

77-4 
82.8 

74-3 
93-7 
44-5 
68.2 



510 

249 

324 

II 

1,317 

563 

238 

133 

54 

I 

42 

262 



20.0 



29.9 



37-2 



25-9 

43-8 

120.0 



527 
407 
233 
129 
200 
37 



63 



58.7 
37-3 
35-8 
12.6 
66.5 
57-0 
28.0 
33-4 
17-7 
16.5 
21.9 
38.4 



53-6 
40.6 
30.2 
21.3 
28.6 
17.4 



-30 



17.9 



5 43-9 



37-6 



'Compiled from the Reports of the Eleventh Census, 1890. 
Including West Virginia. t See South Dakota. 



§ Dakota Territory. 



CENSUS OF THE INSANE 



419 



APPENDIX B. 

Number of Insane Enumerated in Hospitals at Each Census from 1880 to 

1910 Inclusive, with the Ratios per 100,000 of the 

General Population.* 

The ratio per 100,000 of population for the year igo4 is figured on the estimated 
population tor that year only. 



Division and State. 



Jan. I, 1910. 



Jan. I, 1904. 



Number. 



Per I Per 

100,000 ! ^ , 100,000 

popula-i i*" umber, popula- 
tion. I tion. 



June I, 1890. 



June ii iS 



I Per Per 

-. , 100,000 ., , 100,000 

Number, popu, a. Number, popula- 
tion. I tion. 



United States |i87,79i 

Geographic Divisions. | 

New England 

Middle Atlantic 

East North Central. 
West North Central. 

South Atlantic 

East South Central. 
West South Central. 

Mountain 

Pacific 

New England. 

Maine 

New Hampshire. . . . 

Vermont 

Massachusetts 

Rhode Island 

Connecticut 



204.2150,151 183.6 



19,580 

52,380 

41,286 

22 , 683 

19.952 

9.759 

8,413 

3.574 

10,204 

1,258 

909 

990 

11,601 

1.243 

3,579 



Middle Atlantic. 

New York 

New Jersey ....... 

Pennsylvania 

East North Central. 

Ohio 

Indiana 

Illinois 

Michigan 

Wisconsin 

Minnesota 

Iowa 

Missouri 

North Dakota 

South Dakota 

Nebraska 

Kansas 



298.8 
271 .2 
226.0 

194.9 
163.06 

116. 
95.8 

135.7 
243-4 

169.5 

211. 1 
278.1 
344-6 
229.1 
321. 1 



31,280 343-2 

6,042 I238.1 

15,058 196.4 



South Atlantic. 

Delaware 

Maryland 

Dist. of Columbia. 

Virginia 

West Virginia 

North Carolina.. . . 
South Carolina.. .. 

Georgia. 

Florida 



10,594 
4.527 

12,839 
6,699 
6,587 
4.744 
5.377 
6,168 
628 
864 
1,990 
2,912 



222.2 
167.6 
227.7 

238.4 
282.2 
228.5 
241.7 

187.3 
108.8 
148.0 
166.9 
172.2 



441 I218.0 
3,220 248.6 
2,890 872.09 

3.635,176.3 
I ,722 141. 
2,522 114. 3 
1,541 101.7 I 
3,132 120.0 
849 1 12. 8 



14,855 250.1 

42,562 252.5 

33,0391196.6 

18,595 171.9 

16,514 ,149-1 

7,867 jioo.i 

6,oiol 81.8 

2,529 125.0 

8,180 J267. 2 

885124.3 

496 118. 5 

887254.8 

8,679288.4 

I, 077 229.2 

2,831 287.9 



26, 176 

4.865 

11,521 

8,621 
4,358 
9,607 
5,430 
5,023 
4.070 
4,385 
5,103 
446 
595 
1,536 
2,460 



74,028 118. 2 

7,693 163.7 

21,435 168.8 

15,674 116. 3 

8,641 97.2 

9,007 101.7 

4.493 69.9 

2,043 45-0 

858' 74-2 

4,184 223.6 

612 92.6 
342 90-8 
481 144-7 

4,054 181. I 
660 191. 

1,544 206.9 



329.7 13,434 224.0 

229 .4 1 , 744 1 20 . 7 

169.5 6,257 119. 



196.9 
168.7 

187.7 
211. 9 
232.0 
217.8 
196.7 
160.8 
108. 1 
127.2 
138. 1 
158.7 



353 184.7 
2,505 204.2 
2,453 823.09 
3.137 162.6 



1,475 
1,883 
1,156 
2,839 
713 



139.9 
93.8 
82.3 
120.4 
116. 9 



4,960 

1.798 

4,767 

2,771 

1.378 

1.859 

2,030 

2,417 

200 

232 

642 

1,261 



142 

1 ,416 

1,496 

1,764 

860 

972 

664 

1,491 

202 



135-I 

82.0 

124.6 

132.3 

81.7 

142.8 

106.2 

90.2 

109.5 
70.6 
60.6 
88.4 

84.3 
135.8 
649-3 
106.5 
112. 7 

60. 1 

57-7 

I 81. 1 

51-6 



40.942 


81.06 


5.294 


132.0 


12,710 


121. 1 


8,966 


80.0 


3.493 


=;6.7 


4,660 


61.3 


2,549 


45.6 


800 


24.0 


107 


16.4 


2,363 


212.0 


403 


62.1 


288 


83.0 


454 


1,^6.6 


3.085 


173.0 


392 


141. 8 


672 


107.9 


8,079 


is8.q 


1,632 


144.3 


2,999 


70.0 


3,499 


109.4 


920 


46.05 


2,195 


71.03 


1,122 


68.5 


1.230 


93.5 


708 


90.7 


913 


.S6.2 


1.350 


62.3 


\ ^ 


20.7 


175 


38.7 


319 


32.0 


912 


97.5 


860 


484.2 


1,098 


72.6 


394 


63.7 


269 


19.2 


425 


42.7 


626 


40.6 


76 


28.2 



Insane in Hospitals, etc., Bureau of the Census, 1914, page 21. 



420 



INSTITUTIONAL CARE OF THE INSANE 



Insane Enumerated in Hospitals (Continued). 



Division and State. 



East South Central. 

Kentucky 

Tennessee 

Alabama 

Mississippi 

IVest South Central. 

Arkansas 

Louisiana 

Oklahoma 

Texas 

Mountain. 

Montana 

Idaho 

Wyoming 

Colorado 

New Mexico 

Arizona 

Utah 

Nevada 

Facific. 

Washington 

Oregon 

California 



Jan. I, 1910. 



Number. 



Per 

100,000 
popula- 
tion. 



3,538 154. 5 
2,204 
2,039 
1,978 



1,092 
2,158 
I. no 
4,053 

697 
388 
162 
1,199 
219 
337 
342 
230 

1.987 
1,565 
6,652 



100.9 
95-04 

IIO.I 

69.4 
130.3 

67.0 
104.0 

185-3 
119. 2 
III .0 
150. 1 

66.9 
164.9 

91.6 
280.9 

174.0 
232.6 
279-8 



Jan. I, 1904. 



Number. 



Per 

100,000 
popula- 
tion. 



3,058 
1,713 
1,603 

1,493 

667 
1,585 

413 
3,345 

543 

255 
96 
754 
113 
224 

344 
200 

1,178 
1,285 
5,717 



139-1 
82.3 
82.6 
91.0 

47-4 
107.0 

37-4 
99-7 

186.3 

115. 3 

85.8 

119. o 

46.5 
146.9 
no. 3 
352.8 

158.2 
253.2 
316.0 



June I, 1890. 



Number. 



Per 
100,000 
popula- 
tion. 



1,991 
806 

1,014 
682 



390 
608 



1,045 

172 
63 
23 

239 



65 
124 
172 

341 

554 

3,289 



June I, 1880. 



Per 

^, , 100,000 

Number.'popuia. 

1 tion. 



107.1 
45.6 
67.0 
52.9 

34-6 
54.4 



46-7 



130. 1 
74-7 
37-9 
58.0 



109.0 

59-6 

375-9 

97.6 
176.6 
272.2 



1,404 

385 
373 
387 



450 



350 
44 



85.2 
25.0 
29.5 
34-2 



47.9 



112. 4 



17.5 



91 121. I 

262 1149.9 

2,010 232.5 



APPENDIX C. 
Population of the Colonies in 1715. 

New Hampshire 9,650 

Massachusetts 96,000 

Rhode Island 9,ooo 

Connecticut 47.500 

New York 3i.ooo 

New Jersey 22,500 

Pennsylvania 45,8oo 

Maryland 50,ooo 

Virginia 95,ooo 

North Carolina ii>200 

South Carolina 16,750 

Whites 375,750 

Blacks 58,850 



434,600 
In Alaryland in 1698 Governor Nicholson declares: "Here are 
no beggars ; such as are superannuated are reasonably well pro- 
vided for by the counties." 



III. 

FEEBLE-MINDED IN INSTITUTIONS.' 

As has been noted in the previous chapter, an attempt was made 
to enumerate all the mentally defective in the general population 
in connection with the population censuses from 1850 to 1890, 
inclusive. On account of the different methods adopted in dif- 
ferent years, however, the results cannot be regarded as complete 
or comparable. As regards the feeble-minded, the enumeration 
from 1850 to 1880 covered chiefly those whose idiocy or imbecility 
was apparent. In the report for 1890, the term " feeble-minded" 
was adopted to cover those on the border-line of mental deficiency, 
who were evidently not idiots in the ordinary acceptance of the 
word. Since 1890, however, no general enumeration has been 
attempted by the Bureau of the Census of this large and ill-defined 
class. 

Formerly almost all of the class under institutional care were 
in almshouses or in asylums for the insane. In 1890 only 16 states 
had provided separate institutions for the feeble-minded, and the 
number of such institutions was only 24. In 1904 the number of 
states making such provision was 25, and the number of institu- 
tions 42. In 1910 there were 63 institutions reported by 31 states. 
In 1 9 14 there were only 7 states which made no special provision 
for this class of defectives. 

In the 1890 census there were 5254 feeble-minded in special 
institutions, and 2469 in hospitals for the insane ; in addition 781 1 
inmates of almshouses were returned as " idiots," makng a total of 
15.534 feeble-minded and idiots. In 1904 the number in special 
institutions was 14,347 and in 1910, 20,731. The 1904 and 1910 
censuses made no special enumeration of the feeble-minded in 
hospitals for the insane, nor in reformatories or other correctional 
institutions ; but the 1904 report on paupers showed 16,551 inmates 
of almshouses classed as feeble-minded, which number was re- 
duced in the report of 1910 to 13,238. 

^ Compiled from " Insane and Feeble-minded in Institutions. 1910," Bureau 
of Census, Washington, D. C. 1914. pp. 183-184. 



422 INSTITUTIONAL CARE OF THE INSANE 

On January i, 1904, therefore, there were 30,898 feeble-minded 
persons either in special institutions or in almshouses, and on Jan- 
uary I, 1 910, 33,969. 

. According to the report of the Massachusetts State Board of 
Insanity for 19 12, there were 5007 feeble-minded enumerated in 
the general population. In addition 245 were reported by over- 
seers of the poor, making a total of 5252 not in institutions. The 
number in institutions was 2587, making the total number of 
feeble-minded in the state 7839. It is of interest to note that if the 
proportion of feeble-minded to the total population was the same 
for the entire United States as it was in Massachusetts according 
to this census, the total number of feeble-minded would be over 
200,000. This would indicate that not one-tenth of the feeble- 
minded are being cared for in special institutions. 



PART II 

GENERAL HISTORY OF CANADA 



CHAPTER XIII 
GENERAL CONSIDERATIONS IN CANADA 



34 



LAWS FOR THE COMMITMENT OF THE INSANE 
IN CANADA. 

The committee has, through the kind efforts of several super- 
intendents of Canadian institutions, succeeded in procuring copies 
of the laws of commitment in the following provinces : Alberta, 
British Columbia, Manitoba, New Brunswick, Nova Scotia, 
Ontario, Prince Edward Island, Quebec, Saskatchewan and 
Yukon Territory. 

For the most part the laws of commitment seem to have been 
modeled upon those of older provinces, notably those of Nova 
Scotia and New Brunswick. It is evident, upon looking over 
the laws in Manitoba, Alberta, Saskatchewan and Yukon, that 
the provisions for the commitment of patients to institutions have 
been taken almost literally from the former statutes, and the laws 
of the newer territories show no change from practices in the 
older provinces. This has been largely due to the fact that at 
first, before institutions were established in growing provinces, 
no institutions existed for the care of the insane at home. It was 
necessary to arrange for them in the institutions of the older 
provinces. It w-as natural therefore that whenever a territory 
erected and organized an institution, the laws with which the 
officials had become familiar were generally adopted in spirit and 
frequently in form. 

Legislation, however, in the Province of Quebec for the com- 
mitment of the insane proceeds upon somewhat different lines, 
and its peculiarities deserve some special notice. 

In the case of private patients it is provided that they may be 
admitted upon certificates of insanity signed by two physicians 
possessing certain qualifications. These men must state facts 
based upon their own personal observation in giving certificates 
of insanity. 

It is further provided that the medical superintendent of the 
asylum appointed by the government and representing the state 
shall join in the completion of a patient's admission and shall 
examine him within three days of his admission and forward a 



428 INSTITUTIONAL CARE OF THE INSANE 

report under oatli to the Provincial Secretary, who shall imme- 
diately furnish a copy of it to the parish priest or minister of the 
place whence the patient comes, or if the patient is a foreigner, to 
the consul of his country. We know of no other country where 
the parish priest or minister is considered in the admission of a 
patient to an institution. 

It is provided also that public patients must, in addition to 
certificates from two physicians, furnish certificates from a mayor 
or counselor or the secretary-treasurer of the municipality as to 
their indigence for the guidance of the Provincial Secretary, who 
is required to say what proportion of their expenses in the insti- 
tution shall be paid by the individual or by the public. 

In nearly all of the other provinces an application must be made 
to a justice of the peace for the commitment of a supposedly 
insane person to an institution. 

If the patient is found to be insane an application must then be 
made to the superintendent of the lunatic asylum with a state- 
ment of his case in order to procure consent to bring him to the 
institution. 

In a number of the provinces it is not lawful to transfer an 
insane man to a hospital without prior receipt of such consent. 

The effect of such preliminaries in newly settled regions, where 
mails are infrequent and travel necessarily slow, must be to delay 
greatly the admission of patients to institutions. Evidently the 
provision grew out of the fact that nearly or quite all institutions 
were inadequate to meet the demands upon them and it was impos- 
sible to receive patients promptly whenever mental disease devel- 
oped. The effect, however, of the provision has undoubtedly 
been to increase the list of incurable insane, most of whom remain 
in jails or other places of confinement, under unfavorable con- 
ditions for a long time before admission can be secured. 

In two provinces only are provisions of law found for the 
admission of voluntary patients. In the remainder of the prov- 
inces and territories special emphasis seems to be placed upon the 
fact that the insane person is dangerous to be at large, little con- 
sideration being given to the need of treatment to promote re- 
covery. It is evident that when the country becomes more thickly 
settled and pioneer conditions disappear there will be a more 
emphatic demand for the curative treatment of the curable insane. 



LAWS OF COMMITMENT IN CANADA 429 

ALBERTA. 

When information is laid before a justice of the peace that any 
person is suspected or beHeved to be insane the justice shall issue 
his warrant to apprehend him and cause him to be broug^ht into 
court. 

The justice shall then proceed to hear evidence under oath as 
to his insanity and the danger to be apprehended from it, his 
place of residence and other facts in reference to his civil con- 
dition. The justice may adjourn the inquir>^ from time to time 
and recommit the prisoner to jail until a proper inquiry has been 
made, but in no case shall the adjournment be for more than 
three days. 

If after hearing the evidence the justice is satisfied that the 
person is insane and dangerous to be at large, he may commit 
him to the nearest jail or to the custody of any relative or friend 
to await the order of the Attorney General for his removal to an 
asylum or until his discharge by law. 

He shall further make a report, accompanied by the evidence, 
to the Attorney General, who shall have power to order further 
inquiry to be made. 

If the justice is satisfied that the person is not dangerous to be 
at large he shall forthwith discharge him from custody and 
report the proceedings to the Attorney General. 

If the justice is satisfied that the person is insane and danger- 
ous to be at large he shall inquire as to his property and whether 
he shall be maintained as an insane pauper or not. 

The Attorney General may issue his warrant or direct the 
removal to an asylum of any person so committed. He may also 
at any time order the release of such person on trial, either tem- 
porarily or permanently. 

If upon the committal of such person any relative or friend 
believes it to be unwarranted and not justified by the evidence, he 
may, on notice to the Attorney General, apply within four days to 
a judge of the Supreme Court for his discharge from custody on 
the ground that he is not insane, or if insane that he is not dan- 
gerous to be at large. 

The judge shall forthwith examine the person committed as 
insane and the evidence and other papers, and may hear further 
evidence, and if satisfied that he is not insane or dangerous to be 



430 INSTITUTIONAL CARE OF THE INSANE 

at large he may grant a certificate for his discharge from custody, 
or may dismiss the appHcation. 

If any relative or friend of the patient desires to take him to 
an asylum and is competent to do so the warrant for such removal 
may be executed by a relative or friend. A female patient, unless 
accompanied by her father, mother, sister, brother or husband, 
must be placed in charge of and accompanied by a woman. 

If an insane person committed to an asylum is not possessed 
of sufficient means or his relatives are incapable of providing the 
same, the cost of his maintenance and other expenses shall be 
defrayed by the province. 

Any person now or hereafter confined in any jail as insane shall 
be liable for his maintenance if he becomes possessed of property. 

Until the Province of Alberta has an institution of its own the 
asylum belonging to the Province of Manitoba shall be used. 

Every person in custody by virtue of this statute shall remain 
in the asylum until properly discharged. 

BRITISH COLUMBIA. 

Hospitals for the insane are established for the custody and 
treatment of insane persons, and their property and efifects are 
vested in the Crown. The Lieutenant Governor in Council makes 
all rules and regulations for their management and for the admis- 
sion and discharge of patients. 

The Lieutenant Governor in Council appoints in every public 
hospital for the insane a medical superintendent and such other 
officers and servants as are required. The medical superintendent 
directs the medical and moral treatment of patients. He watches 
over the internal management of the hospital and maintains dis- 
cipline. The financial afifairs of the hospital are conducted under 
the control and direction of the superintendent by a clerk. 

The Lieutenant Governor in Council grants licenses to pro- 
prietors or occupiers of private houses to receive insane persons 
for care and treatment, and makes rules and regulations for the 
management of such houses and ai)points an inspector of them. 
No licenses are granted until such houses are found to comply 
with the regulations. 

Removal and Admission of Patients. — No person is committed 
to any hospital or institution for the insane as a lunatic except 



LAWS OF COMMITMENT IN CANADA 43 1 

upon an order of the Lieutenant Governor in Council, without a 
duly executed order signed by a judg'e or registrar of a court of 
record, or a stipendiary ma.gistrate, or a police maj^istrate, or a 
justice of the peace, and with two certificates, in proper form, 
bearing date within one month prior to the day of admission, 
signed by two duly qualified medical practitioners in actual prac- 
tice of their profession, neither of whom shall be a partner, or 
assistant or a near relative of the medical practitioner who signed 
the other certificate. 

A statement signed by a near relative or friend or by a judge 
or other official who signed the order of admission giving the 
antecedents of the patient is also required. Every person thus 
admitted to a public or private hospital remains subject to the 
custody of the medical superintendent until duly discharged. No 
judge or other legal official and no medical practitioner who is a 
near relative of the patient is competent to sign the order of 
admission or the medical certificates in any case. 

Where the admission of a patient becomes necessary under 
an urgency order a single medical certificate is admissible, pro- 
vided that the reasons are stated and that within 14 clear days 
from the admission proper certificates are furnished. Where a 
patient has been committed to a public or private hospital under 
an urgency order it is the duty of the medical superintendent to 
give notice thereof within two clear days to the relatives or 
friends of a patient, if a private patient, or to the superintendent 
of police in case of a free patient ; and the superintendent of 
police or relatives or friends must procure the order or certificates 
required by law within 14 days. 

The superintendent may refuse to admit a patient under an 
urgency order if in his judgment the reasons are not sufficient. 

Committal of Dangerous Lunatics. — If infonnation is laid 
before any magistrate that a person within his jurisdiction is 
believed to be insane and dangerous to be at large, the magistrate 
may issue a warrant for his arrest. This warrant states that 
information has been laid under oath that the person is insane and 
dangerous to be at large. The person alleged to be insane is 
brought before the magistrate, who commits him to a common 
jail or prison or to the custody of the constable or to such other 
safe custody as the magistrate deems fit. But he shall not be 



432 IXSTITUTIONAL CARE OF THE INSANE 

committed beyond three days without a hearings, and at the hear- 
ing the mat^istrate shall hear evidence under oath as to the alleged 
insanity of the person and may adjourn the hearing from time to 
time until a proper inquiry is made. 

If the magistrate is satisfied that the prisoner is insane and 
dangerous to be at large he may commit him to the common jail 
or lock-up, there to remain until duly committed to a public hos- 
pital for the insane or discharged by law. 

No lunatic or other person of unsound mind not convicted of 
crime shall be confined in a jail or lock-up or any other place of 
confinement in the same room with any person charged with or 
convicted of crime. If a female is detained in any jail or lock-up 
as a lunatic the services of a female attendant must be secured to 
take charge of her during her detention. If a female patient is 
conveyed to a public or private hospital, unless accompanied by 
her father, mother, son, brother or husband, she must be placed 
in charge of and accompanied by a female. 

Insane Convicts. — The Lieutenant Governor in Council may 
order the removal of any person found to be insane and under 
imprisonment to a public hospital, there to remain until his dis- 
charge is justified. 

Discharge on Probation. — If the medical superintendent of 
any public hospital for the insane considers it conducive to the 
recovery of any patient to commit him to the care of his friends 
he may allow him to return on probation to them upon receiving a 
written undertaking by one or more of his friends to keep an 
oversight over him. If within six months the insane person again 
becomes dangerous to be at large it is lawful for the medical 
superintendent to direct any constable or peace officer to appre- 
hend and return him to the hospital for the insane. 

The proprietor or superintendent of any private hospital may 
commit a patient to the care of his friends and if he becomes 
dangerous the officers or servants of the private hospital may 
retake him and bring him back to the hospital without a new order 
or commitment. 

If an inmate of a hospital escapes the medical superintendent 
may issue a warrant for his return and any officer or servant of 
the hospital may, in addition, retake such person without a war- 
rant within 48 hours, and within two months after such escape 
with a warrant. 



1 


i 


^§' 


*, 


ip^- 


* 


B'' 


1 


[p; 


?, 


Kt^ 


'fi 


S;'- 


1:1;: 


¥ 






'lb 


i 


"^ 


f 


-'^i 


'-i.- 


^w 






hterft:^ 





o 

00 



LAWS OF COMMITMENT IN CANADA 433 

In case an iimiate of a private hospital escapes it shall be lawful 
for any officer or servant to retake the escaped person within 28 
days and he shall remain in custody by virtue of the authority by 
which he was detained originally. 

Maintenance of Patients. — Before a private patient can be ad- 
mitted to any public hospital a bond must be executed to secure 
proper payment of such amount as may be agreed upon for the 
patient's maintenance. In the case of an insane person sent to any 
public hospital who is under 21 years of age and has a father, or 
mother or guardian liable to maintain him, the medical super- 
intendent may send a copy of the order to the father or mother or 
guardian with a statement of the amount due for him each month, 
and shall also render an account for maintenance and clothing 
with a demand for the payment of the same. 

Penalties. — Any proprietor, manager, officer, nurse or any other 
person who ill treats or willfully neglects a patient shall, on sum- 
mary conviction, be liable to a penalty not to exceed $100 with 
costs or to imprisonment or to fine and imprisonment with or 
without hard labor. If a person receives or detains an insane per- 
son in an unlicensed house he shall be liable to a fine of $200 and 
costs or to imprisonment for a term not to exceed six months, 
with or without hard labor. 

If the keeper of a jail or lock-up illegally detains any person 
on the ground of insanity contrary to the provisions of this act 
he shall be liable to a penalty not to exceed $200, with costs, or to 
imprisonment for any term not to exceed six months, with or with- 
out hard labor. 

MANITOBA. 

Whenever information is laid before one of the justices of the 
peace that a person within his jurisdiction is suspected or believed 
to be insane and dangerous to be at large, and has shown a pur- 
pose of committing some crime for which he would be liable to be 
indicted, or is likely to do bodily harm to himself, the justice may 
issue a warrant for his apprehension. Each warrant under the 
hand and seal of the justice or justices shall order the person to 
whom it is directed to bring the insane person before a justice to 
make inquiry respecting his sanity. Pending such investigation 
the justice may commit him to jail or to the constable. 



434 INSTITUTIONAL CARE OF THE INSANE 

Upon the day appointed the justice proceeds to hear evidence 
in reference to his alleg'ed insanity and directs inquiry to be made 
as to his relatives or friends, that they may be communicated with 
or evidence may be had as to his previous habits. 

The inquiry may be adjourned from time to time, but no ad- 
journment shall be for more than three days. 

If a justice is satisfied that the person is insane and dangerous 
to be at large he may commit him under his warrant to the com- 
mon jail of the district until he be removed to an asylum or dis- 
charged according to law. Or if, in the opinion of the justice, 
he should not be committed to the common jail, he may be com- 
mitted to the custody of any relative or friend to await the order 
of the Attorney General to have him removed to an asylum. 

If it appears to the justice or justices that the person is not 
insane or is not dangerous to be at large, then the justice shall dis- 
charge him from custody. 

It becomes the duty of the justice to make inquiry as to whether 
the prisoner is possessed of property and where it is situated; also 
the number of persons dependent upon him for support, in order 
to ascertain whether or not he shall be supported as an insane 
pauper. 

The Attorney General may order the removal from the jail to 
an asylum of any person confined in a jail as above. But no such 
person shall be committed to an asylum unless two legally qualified 
medical practitioners have each, separately from the other, per- 
sonally examined him and certified that he is insane. 

Discharge. — Any judge of the King's bench of the county court 
may, on application, certify that he has personally examined a 
person thus committed and that in his opinion he is not dangerous 
to be at large and is not a proper person to be confined in an asy- 
lum. Or two legally qualified medical practitioners may certify in 
like manner, and such person shall forthwith be discharged by the 
keeper of the jail, and such certificates shall be sufficient authority 
for his doing so. 

Any person in any asylum in the Province of Manitoba shall 
remain subject to the custody of the officers and other persons in 
charge of such asylum until discharged under the provisions of 
this act. 



LAWS OF COMMITMENT IN CANADA 435 

If any relative or friend of a patient committed to an asylum 
desires to take him to such asylum and is competent to do so, 
the warrant for commitment may be delivered to him instead of 
to an officer. No person of unsound mind shall be confined in a 
jail or lock-up in the same room with a person charged with or 
convicted of any crime. 

Every person detained in an asylum shall be discharged as 
soon as, in the opinion of the superintendent, he is restored to 
reason or is competent to act for himself. 

A patient may be removed from an asylum with the consent of 
the superintendent by his relatives or friends if the superintendent 
considers that they are able to take proper care of him, and the 
superintendent may require them to give sufficient security for his 
proper care and maintenance. 

A patient not recovered may be discharged upon the certificate 
of the superintendent that he is harmless and will probably con- 
tinue so and is not likely to be improved by further treatment in 
an asylum ; but he shall first notify the person or persons at whose 
instance the patient is detained, and unless they within two weeks 
furnish satisfactory proof of the necessity for further treatment 
the patient shall be discharged. 

In case the superintendent of an asylum considers it conducive 
to the recovery of any person that he be committed for a time to 
the custody of his friends the superintendent may allow him to 
be returned on trial to them, upon receiving a written undertak- 
ing by one or more of them that they will keep an oversight over 
him. These provisions do not authorize the temporary discharge 
of any person who has been imprisoned for an offence, whose 
period of sentence has not expired. 

If within a period of six months from such temporary dis- 
charge on trial an insane person again becomes dangerous to be 
at large or requires treatment in an asylum, it shall be lawful for 
the superintendent to authorize and direct that he be apprehended 
and returned to the asylum. 

Only legally qualified practitioners are qualified to grant medical 
certificates under this act. 

It is provided that no insane person shall be confined in any 
jail except there is lack of accommodation in an asylum, and then 
only with the consent of the Attorney General. 



436 INSTITUTIONAL CARE OF THE INSANE 

NEW BRUNSWICK. 

Prior to the admission of any patient to the provincial hospital a 
permit must be received from the medical superintendent. To 
procure this medical certificates must be filed with the superin- 
tendent from physicians duly registered in the Province of New 
Brunswick, certifying after an examination that the person is 
insane and needs care and treatment, and that the opinion has 
been formed on facts indicating insanity observed at the time of 
the examination. Accompanying such certificate shall be a his- 
tory giving as full details as may be acquired concerning the 
patient. In addition there shall be a certificate from the clerk of 
the town or city or the secretary of the county from which the 
patient is to be sent, also from the nearest of kin of the patient 
as to whether he has sufficient estate to support him in the hospital 
while under treatment. If two physicians' certificates are used 
they must be furnished by physicians who do not bear the relation 
of partners, brothers, father or son to each other. 

The friends of a patient may have the medical examination 
made and procure the necessary certificates, and, if a permit to 
enter the hospital is issued, defray the expenses connected with 
conveying the patient to the hospital. If, however, they cannot 
do so, application should be made to a municipal officer to authorize 
a medical examination and the preparation of the certificate, in 
which case the municipality shall pay the physician's fees and the 
cost of transportation. If a municipality pays these expenses it 
can recover them from the relatives or those liable for his support. 

If a patient has no friends or they decline to act, two rate- 
payers may make application to a municipal officer for the 
medical examination. Any person who knowingly or willfully 
makes or joins in making or advises the making of a false certifi- 
cate whereby a sane or insane person is committed to the hospital 
or whereby any insane person is sought to be made a public charge, 
shall be liable to a penalty not to exceed $200, and if a physician, 
he shall be deprived of the right to practice his profession for a 
period of one year. 

Patients whose friends are able to pay the entire cost of main- 
tenance may be granted admission to the hospital on two certifi- 
cates of physicians, without certificates from the clerk or munic- 
ipal officer or a certificate from the nearest of kin. 



LAWS OF COMMITMENT IN CANADA 437 

A fee of $20 is imperative upon admission in all cases admitted, 
and if not paid when the patient is brought to the hospital the 
treasurer of the municipxality may be required to pay it by the 
medical superintendent. 

When a female patient cannot be accompanied by a relative a 
woman must come with her. 

NOVA SCOTIA. 

An application for admission is made by the nearest relations 
or friends to the medical superintendent of the hospital, upon a 
prescribed blank, giving a full history of the patient's mental dis- 
ease and the circumstances of his attack. This is sworn to before 
a justice of the peace and executed within a period of 14 days 
subsequent to the last interview with the patient. 

No patient can be admitted unless a reply to this application has 
been received from the medical superintendent enclosing an order 
for admission. 

Two medical certificates are presented, executed by medical 
practitioners duly qualified in Nova Scotia and authorized to 
execute such a certificate. These certificates are dated within 14 
days of the commitment and must be the result of a personal 
examination. The second certificate cannot be signed by the 
father, brother, son or assistant of the medical practitioner who 
signed the first certificate. An order shall be granted by the Com- 
missioner of Public Works and Mines for the admission of the 
patient to the hospital, provided he is not idiotic or epileptic 
(even if insane though not violently insane), or is not suicidal 
or dangerous to the life and property of others, or a person of 
long standing insanity who is not likely to be benefited by hos- 
pital treatment. 

The medical certificates and orders of admission are sufficient 
authority for any person to convey a patient to the hospital and 
equal authority to the medical superintendent of the hospital to 
retain him under treatment until he is duly discharged. 

Patients found wandering at large and about whom nothing is 
known, or who have been previously under care in the county 
asylum, cannot be received or detained in the hospital except 
under a special warrant. 

35 



438 INSTITUTIONAL CARE OF THE INSANE 

There are county asylums in the provinces to which acute cases 
may be admitted only for care pending arrangements for their 
admission to the Nova Scotia Hospital. Cases of long standing 
may be admitted directly to county institutions on certificates 
similar to those required for the Nova Scotia Hospital, but a war- 
rant must be sent by a stipendiary magistrate or a justice of the 
peace. A patient thus committed to a county asylum may be sub- 
sequently sent to the Nova Scotia Hospital upon the certificates 
under which he was committed to the county asylum, but a new 
warrant is required. 

In cases which are urgent or in violent cases where, from infor- 
mation furnished, the superintendent believes a delay in admission 
may be injurious to the patient, he may authorize him to be for- 
warded to the hospital without a statement of particulars, but 
medical certificates and warrant (when warrant is required) shall 
be forwarded with the patient to the medical superintendent. 

The following provision is made for the admission of voluntary 

patients : 

The commissioner, on the recommendation of the medical superintendent, 
may grant an order for the admission to the hospital as a voluntary patient 
of any person who is desirous of submitting himself to treatment, and who 
makes written application therefor, and whose mental condition is such as 
to render him competent to make such application. Such person shall not 
be detained for more than three days after having given notice in writing 
of his intention to leave the hospital. All provisions of this chapter as to 
maintenance of patients shall apply to such voluntary patients. 

ONTARIO. 

Admission of Patients. — No person except a voluntary patient 
can be admitted to a hospital for the insane without the certificates 
of two legally qualified medical practitioners, accompanied by 
the family and financial history in the prescribed form and upon 
notice from the superintendent of the hospital that a vacancy 
exists. Each certificate shall state that the patient was personally 
examined by the medical practitioner ; the facts upon which he 
formed his opinion must be stated and facts learned from other 
persons must be indicated. Each certificate shall be signed in the 
presence of two subscribing witnesses and Ijear date within three 
months of the admission of the patient. 



LAWS OF COMMITMENT IN CANADA 439 

Patients in indigent circumstances who are proper subjects for 
hospital treatment may be examined at the expense of the munic- 
ipality, provided that the head of the municipality is satisfied 
that they are in destitute circumstances. 

Admissions of Voluntary Patients. — The superintendent of the 
hospital may receive and detain any person suitable for care and 
treatment who voluntarily makes written application and whose 
mental condition is such as to render him competent to do so. He 
shall not be detained more than five days after he has given notice 
in writing of his desire to leave the hospital. Within three days 
after his admission the superintendent shall transmit to the 
inspector his clinical record ; he shall also transmit, on the first 
day of each month, the names of all voluntary patients in the 
hospital. 

Admission of Dangerous Patients. — Upon information laid 
before him any justice of the peace may issue a warrant to appre- 
hend any insane person alleged to be dangerous to be at large. 

Any apparently insane person conducting himself in a dis- 
orderly manner may be arrested without warrant by any peace 
officer and detained in some safe and comfortable place, not a jail, 
lock-up or reformatory, until the question of his insanity may be 
determined. 

Immediately upon the arrest of such person he shall be examined 
by one or more legally qualified medical practitioners appointed 
for the purpose, and the justice shall also hold a hearing, in 
addition to the examination, and receive testimony on oath from 
friends or relations or any person acquainted with the circum- 
stances of the case. If the medical practitioners do not agree 
they may examine the alleged insane person again within a week 
and give new certificates if they change their opinions as to his 
insanity. If he is found not to be insane he shall be discharged. If, 
however, the patient is found to be insane and dangerous to be at 
large the justice shall transmit the evidence to the inspector, who 
shall arrange for his admission to a hospital and issue his warrant 
for his transfer thereto. 

If a person so certified by the justice to be insane is not in desti- 
tute circumstances the expenses of his examination may be re- 
covered from his estate or the persons liable for his maintenance. 



440 INSTITUTIONAL CARE OF THE INSANE 

Insane Prisoners. — The Lieutenant Governor, upon evidence of 
the insanity of any person in any prison other than a penitentiary, 
may by his warrant order his removal to a place of safekeeping 
until such time as a certificate is given of his complete or partial 
recovery. The Lieutenant Governor may then issue an order for 
his reimprisonment or may otherwise discharge him. 

Discharge of Patients. — All persons admitted to a hospital by a 
warrant from the Lieutenant Governor may be discharged by the 
Lieutenant Governor, by the inspector or the superintendent of 
the hospital. 

Escapes and Recommittals. — A patient escaped from a hospital 
may be arrested by the officer or any servant of the hospital with- 
out a warrant within 48 hours after such escape ; also within one 
month after such escape upon a warrant from the superintendent. 
The superintendent, whenever he believes it conducive to the re- 
covery of a patient, may commit him to the custody of his friends 
upon receiving a written undertaking by one or more of them to 
take care of him. This action does not apply to persons in prison 
for an ofifence. If within six months such temporarily discharged 
person becomes dangerous the superintendent may authorize and 
direct a constable or peace officer or any other person to return 
him to the hospital. 

Maintenance of Patients. — If a patient in a hospital be under 
age and has a father and mother or a guardian able to pay for his 
maintenance, the bursar of the hospital is authorized to send a 
written notice of the amount to become due for his maintenance 
quarterly. If the payment of this sum is refused the inspector 
may apply to the judge of the county or district court for an order 
for such payment. If the judge is satisfied that the person against 
whom the application is made is liable he may make an order 
accordingly. The inspector may also recover such sum due for 
maintenance, but he shall not enforce payment until after inquiry 
as to the claims of the patient to be maintained by the person 
liable. 

If property has been received by the inspector and the Lieu- 
tenant Governor authorizes him to do so he may pay to any mem- 
ber of the family of such patient such amount as may be deemed 
proper. Each gift, claim, alienation, conveyance or transfer of 
property of any person who is or becomes an inmate of the hos- 



LAWS OF COMMITMENT IN CANADA 44I 

pital shall be deemed void and fraudulent as against the inspector, 
if the same has not been made for full and valuable consideration 
actually placed. 

QUEBEC. 

All lunatic asylums in the province which have received grants 
from the government are under its control ; all other asylums are 
under its supervision only. The Lieutenant Governor appoints a 
medical superintendent for each asylum under a contract with the 
government ; he also appoints in addition an assistant medical 
superintendent and two house physicians for the three asylums, 
known as St. Jean de Dieu, Verdun and Beauport. 

The Duties of the Medical Superintendent. — The medical super- 
intendent supervises the admission and discharge of patients. 

He controls the medical service, the classification of patients 
and their treatment. 

He makes an annual report to the Provincial Secretary respect- 
ing the patients under his care. 

He formulates all rules and regulations for the medical, moral 
and physical treatment of patients. 

He requires proprietors to dismiss nurses or guardians for 
incompetence or insubordination. 

Assistant Medical Superintendents and House Physicians. — The 
assistant medical superintendent exercises the powers of the super- 
intendent in event of his absence or inability to act. The house 
physicians devote their whole time to the service of their patients. 
They reside near the asylum. They prescribe the treatment, 
medical and moral, approved by the medical superintendent and 
execute all rules and regulations. 

Private Patients. — Patients are admitted to lunatic asylums 
upon certificates that they are insane signed by two physicians 
who are not medical partners, nor brothers, nor in relation of 
father and son to each other, to the proprietors of the asylum or 
to the patient. They must specify in their certificates such facts 
as have come under their own personal observation. 

The medical superintendent examines each patient within three 
days of his admission and forwards a report under oath to the 
Provincial Secretary, who immediately furnishes a copy to the 
parish priest or minister of the place whence the patient comes, or, 
if he is a foreigner, to the consul of his country. If there is 



/)/j g INSTITUTIONAL CARE OF THE INSANE 

opposition to the confinement of such patient, application is made 
for his discharge to a judge of the Superior Court of the district. 
The judge may refer the matter to the judge of the district from 
which the patient comes or he may order the discharge. The 
medical superintendent is required to forward every month to the 
Provincial Secretary the name of each private patient admitted 
or discharged, also the date of admission or discharge, the names 
of persons applying for his admission or discharge, the names 
of the two physicians who certified as to his insanity, and the date 
of his escape, death or discharge. 

Public Patients. — The following persons may he admitted to 
lunatic asylums at the expense of the government and of cities, 
towns and counties : 

1. Persons who cannot from their own property or through 
some person compelled by law to support them pay fully or in 
part the expense of custody, maintenance or treatment in an 
asylum. 

2. Idiots or imbecile persons who are dangerous or a source of 
scandal or subject to epilepsy and are unable to pay for custody, 
maintenance or treatment. 

No patient can be admitted unless there be presented to the 
medical superintendent of the asylum an application signed by 
relatives, friends or protectors attested before a public officer, 
physicians' certificates of insanity from physicians of the same 
qualifications as those prescribed for private patients, and cer- 
tificates from a mayor, or councillor or secretary-treasurer of 
the municipality, attested before a public officer. 

If a portion of the maintenance of the patient is to be paid by 
relatives the Provincial Secretary shall decide what portion it 
shall be. 

The medical superintendent shall furnish a permit for the 
admission of the patient and no patient shall be brought without 
it. In case of an emergency the medical superintendent may dis- 
pense with a physician's certificate, which must, however, be fur- 
nished within eight days. Certificates of physicians shall be void 
unless executed within a period of not more than 20 days prior 
to being sent to the medical superintendent. 

The medical superintendent or his assistants may at all times 
give a written authorization to admit a relative, friend or physician 



LAWS OF COMMITMENT IN CANADA 443 

to visit a patient. Every letter written by a patient, addressed to 
members of the executive council, the inspector of the asylum, the 
family of the patient or those who obtained his confinement, shall 
be forwarded unopened to its address. 

Every person related or allied to a patient in an asylum may 
obtain his release by an application to the medical superintendent 
and by binding himself to take care of him, provided that the 
superintendent is of the opinion that the patient may be set at 
liberty without danger. 

If an insane patient dies in an asylum the proprietors must 
notify the medical superintendent and furnish all necessary m- 
formation. 

Insane People in Jails. — Upon application and a proper certifi- 
cate of insanity from the superintendent of an asylum for the 
insane or any physician appointed by the Provincial Secretary, a 
person confined in a jail for any offence may be transferred to an 
asylum upon an order from the Lieutenant Governor. The pro- 
prietors of each asylum are required to furnish a list of the names 
of all persons confined in an asylum who have been transferred 
from a jail. Upon report of the medical superintendent or of his 
assistants that an insane person confined in an asylum under 
authority of the criminal code has recovered, the Lieutenant 
Governor shall order him to be discharged altogether or recon- 
veyed to jail to stand trial or to undergo sentence. 

Dangerous Lunatics. — Dangerous lunatics may be confined in 
an asylum under order of a recorder or police magistrate or upon 
the sworn information of two tax payers that the person endan- 
gers public safety, decency and peace, accompanied by physicians' 
certificates according to regular form. 

Escaped Patients. — If a patient escapes from an asylum each 
officer may apprehend him or cause him to be apprehended and 
brought back without any warrant or within three months under 
a warrant issued by the medical superintendent or assistant. 

Discharged Patients. — A medical superintendent may discharge 
a patient on trial upon the written promise of a relative or friend 
to take care of him and to bring him back if he becomes danger- 
ous. No person shall be detained after his cure has been estab- 
lished by the medical superintendent and an order given for his 
discharge. Any person detained in an asylum may at any time 



> j/^ /^ INSTITUTIONAL CARE OF THE INSANE 

apply to the judge of the district for his discharge from the 
asylum. The judge after proof may order such discharge and 
his decision shall be final and without appeal. 

PRINCE EDWARD ISLAND. 

Prior to the admission of any patient to an asylum it is neces- 
sary to secure a certificate from a regularly qualified physician 
of the province as to his insanity, also a statement giving a history 
of his case to be sent to the medical superintendent for examina- 
tion ; and the answer and approval of the medical superintendent 
shall be received before the patient is forwarded. The practi- 
tioner must be in actual practice in the province and the examina- 
tion must be made during a period of not more than 30 days before 
the application for his admission. 

If the patient is possessed of means a bond must be executed 
binding the signer to pay a weekly sum for the maintenance of the 
patient while in the hospital. If he has no means the patient must 
be received upon a pauper's affidavit with an admission fee of 
$10 or upon an order from the trustees granting free admission. 
What is known as a pauper's certificate shall be sworn to by the 
applicant before a justice of the peace and two justices of the 
peace must certify that the affidavit is correct. The law seems to 
be defective in that it makes no provision for a medical examina- 
tion or certificate or an order from a judge in case of a pauper 
patient, but provides that the order from the trustees granting 
free admission shall be sufficient. 

Criminal Patients. — Criminal cases are admitted upon a war- 
rant from the Lieutenant Governor. 

YUKON TERRITORY, 

If information is laid before a justice of the peace that any 
person is insane or supposed or believed to be, he shall issue a 
warrant to apprehend the person and cause him to be brought 
before him. The justice shall then proceed to hear evidence as to 
his insanity and to ascertain his residence, his profession, his 
means of support and his civil condition, as to whether, if he is 
committed as insane, he should be sent back to his former resi- 
dence and at whose cost. If after hearing the evidence the 
justice is satisfied that he is insane, he shall commit him by war- 



LAWS OF COMMITMENT IN CANADA 445 

rant to jail, there to remain until the pleasure of the commissioner 
of the Yukon Territory is known or until he is discharg-ed by law. 
If it appears that the person is not insane the justice shall dis- 
charge him. The justice may compel the attendance of witnesses 
in making the investigations. 

Removal of Insane Persons in Custody by Order of the 
Lieutenant Governor. — Whenever under any law or ordinance 
an insane person is kept in custody until the pleasure of the Lieu- 
tenant Governor is known or until such person is discharged by 
law, the Lieutenant Governor may cause him to be removed to 
and confined in any asylum or place of confinement from time to 
time designated for that purpose by the Governor in Council, and 
the superintendent or warden of such asylum or place of confine- 
ment shall receive him and detain him therein until the pleasure 
of the Lieutenant Governor is known or until he is discharged 
by law. 

Persons adjudged to be insane in Yukon Territory are, by 
warrant of the commissioner, removed to and confined in the pro- 
vincial asylum of the Province of British Columbia at New West- 
minster, such being the asylum or place of confinement designated 
for that purpose by the Lieutenant Governor. 

NEWFOUNDLAND. 

Commitment of Insane. — Patients are admitted on an order 
from a stipendiary magistrate upon an application in writing, or 
upon a warrant if found dangerous to be at large. Such order 
must bear date within 14 days prior to the reception of such per- 
sons and be accompanied by certificates of two qualified medical 
practitioners. The magistrate must cause a full and particular 
inquiry to be made into the sanity of the alleged lunatic, which 
inquiry may be ex parte. If the magistrate is satisfied from the 
medical and other testimony that he is a proper person to be con- 
fined in the asylum, he shall grant an order for his reception and 
detention. The expense of the inquiry and of conveying him to the 
asylum, when a pauper, is a charge on the Commissioner of 
Public Charities. 

In case of emergency the superintendent of the asylum may 
receive and detain any person as a lunatic for a period not exceed- 
ing three days, on a certificate of one duly qualified medical 
practitioner. 



II. 

CARE OF THE INSANE IN CANADA PREVIOUS TO 

THE ESTABLISHMENT OF PROVINCIAL 

INSTITUTIONS. 

We learn from Dr. T. J. W. Burg-ess ' that " in 1639 the 
Duchess d'Aiguillon, niece of Cardinal Richelieu, founded the 
Hotel Dieu of Quebec for the care of indigent patients, the 
crippled and idiots." Four years later, namely, in 1643, Mademoi- 
selle Mance founded the Hotel Dieu of Montreal. 

An ordinance of the 15th of October, 1663, reproduced in the 
" Judgments and Deliberations of the Royal Council," directed 
that " all sick persons " must be returned to France as soon as 
possible. This no doubt included the insane. A mention of an 
asylum, to be situated in Canada, is found in the " Letters Patent " 
granted in April, 1694, to Sister Charon de la Barre, by which 
authority was granted her to establish a " Home," which would 
include the insane of Montreal. In 1747 this "Home" was 
entrusted to the Venerable Widow Youville, with the direct re- 
quest from the Sulpician Fathers that the insane be included. 
This request is in the archives of the Grey Nuns at Montreal.' 
This would indicate that the first care of the insane in North 
America was undertaken by the religious bodies of New France, 
now Quebec. 

No records are available as regards the measure of care meted 
out to the victims of mental disease confined in the " Home " 
under the care of the Venerable Widow Youville, but from the 
histories of subsequent institutions of like character we know that 
the care exercised must have been of a custodial character only. 
The wretchedness and misery of the surroundings of the insane 
in the early hospitals and lack of proper care and medical treat- 
ment from which they suffered are vividly set forth in a report 
made by a special committee of the Legislative Council of Lower 
Canada, published in February, 1824,* which gives various statis- 

* " The Insane in Canada," American Journal of Insanity, Vol. LXII, p. 2. 
^ This was the first hospital to be instituted in North America. 
^ From letter of Dr. T. J. W. Burgess, Montreal, Quebec, May 19, 1913. 
* Reported by the Hon. John Richardson, February, 1824. Quebec, R. E. 
Desbarats, law printer. 



PREVIOUS TO PROVINCIAL INSTITUTIONS 447 

tics and other details regarding the care of the insane, of found- 
Hngs and of sick and infirm poor in the Hopital General at Quebec, 
the Hopital General at Montreal, and in the Ursulines at Three 
Rivers, for the period from 1808 to 1824. 

During early times lunatics, if harmless, were allowed to 
wander about at will, or were cared for at home; if dangerous 
they were incarcerated in jails like ordinary criminals. Towards 
the close of the eighteenth century an act was passed authorizing 
an appropriation for the maintenance of insane persons in the 
Province of Lower Canada, at the rate of one shilling and eight 
pence a day. Under this act the insane were entrusted to the care 
of the religious communities already mentioned, selected in the 
districts of Quebec, Montreal and Three Rivers.^ The report 
made by the special committee in 1824 contains an appendix giv- 
ing copies (in both English and French) of the questions and 
answers received from heads of these three hospitals, as well as 
from their attending physicians and the sheriffs of the three dis- 
tricts, regarding the confinement of the insane in jails and houses 
of correction; also the report made by Dr. Hackett, of the Quebec 
General Hospital, in 18 16, to Sir John Sherbrooke on the subject 
of the insane. 

The above committee was instructed to inquire into the purpose 
for which " public monies " had been expended, and " also to 
enquire and report whether one lunatic asylum for the whole 
province, adapted to the improved modern system of treatment of 
the insane, be not an establishment called for by every principle of 
humanity ; and if so, what the erection would probably cost." 

This report shows that from 1800 to the end of 1823 the sum 
of £17,500, 9s. I id. was expended in all for the insane at Quebec, 
Montreal and Three Rivers. The report further says : 

The returns received from the three nunneries respectively show that at 
the Hopital General, Quebec, where insane are attended gratis by Dr. 
Holmes, senior, there were 18 lodges or cells (12 of which were built at 
the public expense), in size 8 feet long by 7'/^ feet broad and 8 in height. 
There were also 6 cells of a much better description, called by the com- 
missioners "moral cells" (also built at the public expense), about 9 feet 
square and 9 feet high, for patients in a state of mental disease less violent. 
Sixteen persons were confined in the whole ( ?) at Quebec in 1824, and 

* Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." 
Proceedings and Transactions Royal Society of Canada, Second Series, Vol. 
IV. 1808. 



448 INSTITUTIONAL CARE OF THE INSANE 

between 1800 and 1824 the total number was 66 males and 45 females, of 
whom 35 males and 21 females died in that period, while 22 males and 
17 females were discharged as cured or relieved. The committee personally 
visited the above hospital and found everything that regards the manage- 
ment well conducted, and the moral cells neat and clean ; but the others, 
although they were said to be lately much improved, were such as to 
preclude the possibility of treatment of persons confined therein upon a 
regular system with a view to cure. 

At the Hopital General, or Grey Sisters' nunnery, Montreal, where the 
insane are attended gratis by Dr. Selby, senior, there were eight cells, each 
about 8 feet long, 6 feet 3 inches broad and 7 feet 10 inches high. Between 
1800 and 1824, 85 patients were received and confined there, of whom 6 
were there in 1824, 29 had died, and 49 had been discharged as cured or 
relieved. 

At the Ursulines, Three Rivers, there were six cells, each about 8 feet 
long, 6 feet broad and 8 feet high. The whole number of patients confined 
there was 12, of whom 5 had been discharged, while 4 were then in 
confinement. Each of the above cells was intended for one inmate, who 
was solitarily confined therein, day and night, with few exceptions, and 
only removed to another cell when his own cell was cleaned. The cells 
each had a small glazed and grated window of about a foot square in the 
outside wall, and in the passages there were openings above each door 
which were also grated. Through these windows light was admitted and, 
when opened, air. In winter there were stoves in the adjoining passages, 
which heated the cells ; and in summer, a window at each end of the passage 
admitted air ; but the ventilation must have been very imperfect. 

Such arrangements as these did not permit the enjoyment of 
external air or exercise, nor of moral or even of medical treatment, 
upon any system affording a hope of mental cure. The cells were 
simply places of confinement in which the insane were placed to 
prevent their doing harm to others and to diminish the risk of 
harm to themselves which would result from their personal free- 
dom. There was no possibility of beneficial effect upon the un- 
happy patients. The committee expressed the opinion that they 
rather resembled places for criminals (the said six moral cells at 
Quebec excepted), and were more likely to produce or increase 
insanity than to cure it. 

Between 1800 and 1814 there were confined in the cells of the 
three districts 207 insane persons, of whom 93 were discharged, 
88 died and 26 remained in confinement. Any apparent benefit or 
relief afforded must have proceeded from constitutional or acci- 
dental causes, and not from any benefits attendant on moral or 
medical treatment during their confinement in those miserable 
abodes. 



PREVIOUS TO PROVINCIAL INSTITUTIONS 449 

In the year 1818 the sum of £2500 currency was granted for 
erecting- additional cells and making repairs at the General Hos- 
pital of Quebec, and £336 was afterwards granted for other 
repairs thereto. In 1818 £2000 was devoted to a like purpose at 
Montreal. 

The ladies of the Hopital General there and Dr. Selby, Sr., the 
commissioner, to their honor declined to receive the £2000, as it 
would increase what was in itself bad and inadequate to the 
object. 

The committee reported that it was deeply to be regretted that 
so much public money should have been expended in the several 
districts upon these miserable expedients, in lieu of an estab- 
lishment for the insane, when, by the application of that money 
to the same humane object, upon a proper principle, a lunatic 
asylum might have been erected, calculated to do honor to the 
province, instead of being a reproach to its inhabitants. They 
also stated that : 

In the treatment of the insane in other countries a great and happy 
change has been wrought of late years ; coercion and confinement beyond 
that which may be indispensably necessary in special cases are proscribed ; 
and mildness of treatment, with enjoyment of air, exercise and amuse- 
ment out of doors, and comforts within, are substituted where practicable, 
with the happiest effects. To each asylum a considerable portion of ground 
is attached for those purposes. 

The security consistent with the safety of the insane, their connections 
and general society can hardly ever, in the heart-rending circumstances 
attendant on mental derangement, be enjoyed in the dwellings of private 
families ; removal from home, therefore, is generally necessary, in most 
cases desirable, and tends to destroy or weaken the morbid associations. 

The committee also found that the want of a public lunatic 
asylum impeded the administration of justice by obliging the 
judges, from necessity, to condemn insane criminals, when con- 
victed, to be confined in the common jails and houses of correc- 
tion, where their situation was deplorable to themselves and a 
nuisance to the other persons confined therein — besides inter- 
fering with the classification of prisoners. " The turnkeys and 
keepers in those establishments cannot be expected to possess 
qualifications requisite for the management of insane persons. In 
1824 three insane criminals were in the jail at Quebec; seven in 
the jails and two in the temporary house of correction at Montreal. 
There were none at Three Rivers." 



45© INSTITUTIONAL CARE OF THE INSANE 

In the opinion of the committee the benefits of a kmatic asylum 
should be extended to the whole province, with a view to general 
utility and economy, and not to districts. Indeed it might embrace 
both the provinces of Canada, in contribution to the expense and 
enjoyment of its advantages. 

This being a general object of great importance, a portion of 
the public revenue could, with great propriety, in their opinion, 
be applied to the purchase of the ground, the erection of the build- 
ing, and annual support of the establishment. They recommended 
that the site should be healthy and in the neighborhood of a popu- 
lous town ; at such a distance as to possess the advantage of retire- 
ment, yet admit of the benefit of medical aid, and enable the insti- 
tution to be regularly visited, which is of much moment. 

After describing in detail the lunatic asylum at Glasgow, Scot- 
land, and recommending this as a model, the report continues : 

The committee, therefore, cannot but confidently hope in the means being 
supplied, by constitutional authority, for the establishment of an institution 
recommended by the best feelings of our nature, as no human can be 
considered exempt from insanity, that awful visitation of the Almighty. 

And in their final resolutions the committee further said : 

Resolved, as the opinion of this committee, That the cells appropriated 
to the insane in this province do not admit of properly applying either 
moral or medical treatment, with a hope to a mental cure of the unhappy 
persons confined therein, and are more likely to produce or increase in- 
sanity than to remove it. 

Resolved, as the opinion of this committee, That humanity loudly calls 
for the establishment of a lunatic asylum for the whole province, or for 
both provinces, for the reception and treatment for cure of the insane, 
upon the improved modern system, as also for the ultimate care and support 
of such as are incurable, and that such asylum should be erected in the 
neighborhood of one of the populous cities of this province, so as to 
have the benefit of medical aid, and adequate frequent visitation. 

Resolved, as the opinion of this committee, That the monies which 
have been expended for the confinement and support of the insane of this 
province since the year 1800 would have sufficed for the erection of a 
lunatic asylum that would have done honor to the humanity and philan- 
thropy of the country. 

Dr. Hackett, in his letter to Sir John Sherbrooke in 1816, por- 
trays in detail the inadequacy of the treatment of the insane pro- 
vided in the Quebec General Hospital, and concludes as follows : 

The impracticability at present of adopting even any part of the modern 
plan of treating the insane will be obvious to Your Excellency ; therefore. 



PREVIOUS TO PROVINCIAL INSTITUTIONS 45I 

under existing circumstances, I conceive medical treatment perfectly use- 
less, and any attempt at moral, not only absurd, but in truth bordering 
on the ridiculous/ 

The conditions prevailing in the Province of Quebec were 
typical of the conditions existing in the other provinces of Old 
Canada. In New Brunswick, while the population of the prov- 
ince was yet sparse and the insane but few in number, each county 
cared for its lunatics as best it could, the law authorizing " any two 
justices of the peace to issue a warrant for the apprehension of 
a lunatic or mad person and cause him to be kept safely locked in 
some secure place directed and appointed by them, and, if they 
deemed it necessary, to be chained." Under this law the indigent 
insane were confined in jails and poorhouses, while those able to 
bear the expense were sent to asylums abroad.^ This condition 
was in part remedied when, in 1835, a small wooden building in 
the city of St. John, originally erected as a cholera hospital in 
1832, was converted into a temporary asylum for lunatics. This 
institution was the first of its kind in Canada."* 

No provision for the care of the insane existed in Ontario 
previous to the establishment of the Toronto Asylum in 1841. 
Those who could not be cared for at home were maintained in the 

* See the following references : 

Clark, Sir James : " A Memoir of John Conolly, Comprising a Sketch 
of the Treatment of the Insane in Europe and America," pp. 268-277. 
London, 1869. 

Monseignier de Saint : Vallier et L' Hopital General de Quebec. Quebec, 
C. Darveau, 1883. 

Tuke, Daniel Hack : " The Insane in the United States and Canada," 
pp. 189-242. London, H. K. Lewis, 1885. 

" A Report of the Special Committee of the Legislative Council of the 
Province of Lower Canada, appointed to Enquire into and Report upon the 
Establishments in this Province for the Reception and Cure of the Insane, 
for the Reception and Support of Foundlings, and for the Relief and Cure 
of Sick and Infirm Poor, with the Expenses thereof Defrayed out of the 
Provincial Revenue, etc." Reported by the Hon. John Richardson, February, 
1824. Quebec, R. E. Desbarats, law printer. 

DeWolf, James R., M. D. : " Hospitals for the Insane in British North 
America." Journal of Mental Science, London, January, 1869, pp. 466-470. 

^ Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." Pro- 
ceedings and Transactions Royal Society of Canada, Second Series, Vol. 
IV, 1898. 

' Ibid. 



452 INSTITUTIONAL CARE OF THE INSANE 

county jails. In 1830 an act was passed by the House of Assembly 
of the then Province of Upper Canada, authorizing the General 
Quarter Sessions to make provision for the relief of destitute 
lunatics in the home district. This act did not contemplate the 
erection of an asylum, but proposed merely to legalize pay- 
ments for the maintenance of lunatics in county jails. In 1833 it 
w^as extended to all the districts of the province.' 

No reference is found in regard to lunatic persons or paupers, 
in Prince Edward Island, prior to 1820. In that year, however, 
small amounts were granted out of the public funds to some espe- 
cially needy cases. In 1828 the sum of iii8 19s. and 4d. had 
been reported as spent in support of lunatics and other indigent 
persons during the previous year.' There is no record as to how 
this money was spent, or in what the care given to these unfor- 
tunates consisted. The asylum at Charlottetown was opened on 
May I, 1847. 

In Nova Scotia, previous to 1858, pauper lunatics were sent to 
the " Lunatic Ward " of the Provincial and City Poor's Asylum 
in Halifax, or cared for at home. Patients whose friends could 
afford to pay for them found accommodations in the United 
States, or in the adjoining Province of New Brunswick.' The 
asylum at Halifax was opened on December 26, 1858. 

In the early days of British Columbia, when it was yet a Crown 
colony, lunatics were placed in the colonial jail in Victoria.* 

During the rush to the Cariboo gold fields many persons broke 
down under the mental strain and hardships endured. In 1858 
and 1859 the authorities began to send these insane persons back 
to California, whence a number of them had come. This 
continued until the authorities gave the government to understand 
that the practice could not continue. The insane were accordingly 
placed in the jail at Victoria and the more manageable ones were 
sent to the Royal Hospital. These places served for patients of 
the male sex, but when female patients began to appear further 

* Ibid., p. 14. 

' See " The Care of the Insane in Prince Edward Island " in a subsequent 
volume. 

' Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." Pro- 
ceedings and Transactions Royal Society of Canada, Second Series, Vol. 
IV, 1898. 

*Ibid. 



PREVIOUS TO PROVINCIAL INSTITUTIONS 453 

provision was necessary, and accordingly a woman's hospital was 
opened in Victoria. In 1872 the old royal hospital was remodeled 
and made into an asylum proper.' 

Previous to 1871 there seems to have been no provision for 
lunatics in Manitoba. The population was sparse, and among 
Indians insanity was not at all common. In 1871 the dominion 
government established the Manitoba Penitentiary at Lower Fort 
Garry, in one of the old stone warehouses of the Hudson Bay 
Company. Here from 1871 to 1877 the insane were cared for. 
Except in the case of females, no separate provision was made 
for lunatics, they and the convicts being treated alike. In 1883 
the Legislature passed an act authorizing the building of an 
asylum, which was located at Selkirk, and opened in May, 1886.' 

By special arrangement with the Dominion government all cases 
of insanity occurring in the Northwest Territories and Keewatin 
were cared for in the provincial asylums of Manitoba, at a rate of 
$1 per day each.^ This included the insane in what are now the 
provinces of Alberta and Saskatchewan and the Yukon Territory. 

The subsequent establishment of asylums in these territories 
will be treated of in the following chapter. 

* See " History of the Care of the Insane in British Columbia " in a 
subsequent volume. 

* Burgess, Dr. T. J. W. : " Canadian Institutions for the Insane." Pro- 
ceedings and Transactions Royal Society of Canada, Second Series, Vol. 
IV, 1898. 

' Ibid. 



36 



III. 

ESTABLISHMENT OF PROVINCIAL INSTITUTIONS. 

The first provincial institution for the care of the insane in 
Canada was estabhshed at St. Johns, New Brunswick, in 1835, 
It consisted of a small wooden buildin^f originally erected as a 
cholera hospital, which had been converted into an asylum 
for lunatics.^ In 1848 this temporary refuge was abandoned and 
the inmates, 90 in number, transferred to the present institution, 
the erection of which had been begun two years previously.* 

Ontario, then called Upper Canada, was the next of the prov- 
inces to make a movement towards providing for its insane when 
an abandoned jail at York, now Toronto, was fitted up as a tem- 
porary asylum in 1841.^ This establishment was continued in use 
up to 1850, in which year the patients were transferred to the 
present Toronto Asylum." A new hospital is now (191 5) under 
construction at Whitby, which, when completed, will replace the 
Toronto Asylum. 

Kingston Asylum, generally known as Rockwood Hospital, was 
the second asylum in the Province of Ontario, and was opened 
in 1856. It was designed as a criminal lunatic asylum, and re- 
mained in charge of the federal government, as an adjunct to the 
jjenitentiary, until 1877. I^ that year it was purchased by the 
local Legislature and became one of the provincial asylums.' 

The next in order of erection are London Asylum, established 
at Fort Maiden, in 1859, as a branch of the Toronto Asylum, made 
an independent institution in 1861 and moved to its present loca- 
tion in 1870; Orillia, established at Orillia as a branch of the 
Toronto Asylum in 1861, in a large building originally designed 
as a hotel, and abandoned in 1870 on the transfer of the patients 
to a new asylum then opened at London ; Hamilton, originally 
built as an inebriate asylum in 1879, but utilized for the care of the 
insane instead ; Mimico Asylum, opened as a branch of the Toronto 
Asylum in 1890 and made independent in 1894; Brockville Asy- 
lum, opened in 1894 ; Cobourg Asylum, opened in 1902 ; and 

' Burgess, Dr. T. J. W. : American Journal of Insanity, Vol. LXII, p. 3. 
' Ibid. ' Ibid. ' Ibid., p. 5- ° Ibid., p. 6. 



ESTABLISHMENT OF PROVINCIAL INSTITUTIONS 455 

Penetang-uishene, formerly a reformatory, transformed into an 
asylum, which was opened in 1904. In 1876 there was established 
at Orillia, in quarters formerly used as an insane asylum, an asy- 
lum for idiots, which was rebuilt in 1887/ In 1912 there was 
begun at Whitby a new institution, designed to take the place of 
the Hospital for the Insane in the City of Toronto, the site of 
which had been sold by the provincial government. 

Quebec is the only one of the provinces of the dominion in 
which there is no provincial institution for the care of the insane." 
The Quebec Lunatic Asylum, formerly known as Beauport Asy- 
lum, was established in 1845 by three physicians of the City of 
Quebec, Drs. James Douglas, Joseph Morrin and Charles J. Fre- 
mont, who acquired by lease a property in the parish of Beauport, 
once a large stone manor-house, which they converted by additions 
into an asylum. The agreement of the proprietors with the 
government was that they should be paid at the rate of $143 
annually for each public patient. Being subsidized by the province 
the establishment was placed under the supervision of a board of 
commissioners.' 

In 1848 the establishment was removed to a new location about 
a mile distant from the original site and a new asylum erected. 
After successive changes of ownership the asylum passed by 
purchase into the hands of the Sisters of Charity of Quebec in 
April, 1893. 

St. Johns Asylum, the only attempt at state care ever made in 
the Province of Quebec, was established in an old building, for- 
merly used as a court-house, in St. Johns in August, 1861. On 
July 20, 1875, this institution was closed, the inmates being 
removed to Longue Pointe Hospital, under the care of the Sisters 
of Charity.* 

L'Hospice St. Jean de Dieu, or, as it is usually known, Longue 
Pointe Asylum, was established in 1852. It is a proprietary 
institution established by and still the property of the Sisters of 

' Ibid., p. 6. 

^ Burgess, Dr. T. J. W. : " Canadian Institutions for the Insane." Pro- 
ceedings and Transactions Royal Society of Canada, Second Series, Vol. 
IV, p. 47. 

' Ibid., p. 50. 

* See " History of St. Johns Asylum " in a subsequent volume. 



456 INSTITUTIONAL CARE OF THE INSANE 

Charity. The Protestant Hospital, generally known as Verdun 
Hospital, is a corporate hospital, established by a number of Prot- 
estant citizens of Montreal, and opened in 1890. There are besides, 
two institutions which receive idiots as well as aged and infirm 
paupers. These are L'Hospice St. Julien, located at St. Ferdinand 
d'Halifax, and Baie St. Paul Asylum, at Baie St. Paul. The 
former was opened for the reception of idiots in 1873 and the 
latter in 1890. Roth belong to the Sisters of Charity.' 

Prince Edward Island has a provincial hospital for the insane, 
erected in 1847, but idiots and imbeciles are cared for in the pro- 
vincial poorhouse." 

Xova Scotia established a hospital for its insane in 1858. It 
has, however, since 1886, sanctioned the erection of county asy- 
lums, in many cases county asylums combined with covmty poor- 
houses. In 1904 there were 18 of these structures, which housed 
sane adults, children, insane patients, imbeciles, and epileptics.' 

In 1 87 1 Manitoba established its first asylum at Lower Fort 
Garry, in conjunction with the Manitoba penitentiary. In 1877 the 
lunatics were removed to Stony Mountain, where the present peni- 
tentiary had been erected. In 1884 they were brought back to 
their old quarters at Lower Fort Garry. In 1886 the present asy- 
lum, located at Selkirk, was established. The second asylum for 
the insane of the province is located at Brandon, and was opened 
in 1891. 

In 1890 a home for incurables was opened at Portage la Prairie, 
a town some 50 miles west of Winnepeg. Although not intended 
for mental cases, owing to overcrowding at Selkirk there were 
transferred to it on its opening some 17 cases. This action, com- 
bined with the fact that imbeciles and idiots are by law non- 
admissible to the insane hospitals, has led to the adoption of a 
portion of this institution as a refuge for harmless patients of 
these classes. 

British Columbia established a temporary asylum for the care 
of the insane outside the City of Victoria in 1872. This was re- 
moved to New Westminster and made permanent in 1878. This 
institution became overcrowded in 1906 and 1908, and a "colony 
farm " was purchased in the valley of the Frazer River, at a point 

' Burgess, Dr. T. J. W. : American Journal of Insanity, Vol. LXII, p. 7. 
* Ibid., p. 14. 'Ibid., p. 11. 



ESTABLISHMENT OF PROVINCIAL INSTITUTIONS 457 

where it is joined by the Coquitlan River. The provincial govern- 
ment decided to make this a separate institution, however, and it 
was opened as such on April i, 19 13. 

Prior to its organization as a separate province September i, 
1905, Alberta formed part of the Northwest Territory. In 1907 
an act was passed by the Legislature which provided for the 
erection of an asylum, or the procuring of a building for tem- 
porary use until a proper asylum could be established. The result 
was the establishment of the insane asylum at Ponoka, which was 
opened for the admission of patients on July 4, 1911. 

Saskatchewan, like Alberta, became a separate province on 
September i, 1905. In 1906 the Legislature of the province 
passed an act which provided that anyone deemed mentally un- 
sound could be taken to a justice of the peace, who might, did the 
evidence show sufficient reason, commit such person to the nearest 
jail, there to stay until the Attorney General should order his 
removal to an asylum in Saskatchewan or another province. The 
maintenance of all pauper lunatics was made a provincial burden 
by the same law. 

Nothing was done, however, towards the erection of an asylum 
until 191 1, when a site was finally selected near the town of Battle- 
ford, on the Canadian Northern Railway. In August of that year 
work was begun on the new hospital, and it was completed and 
occupied on February 4, 1914. It is known as " The Saskatchewan 
Provincial Hospital." 

There are no asylums for the insane in the Yukon and North- 
west territories. The early care of lunatics and their conveyance 
to an institution in one of the neighboring provinces usually falls 
to the lot of the members of the Royal Northwest Mounted Police. 
Those from Yukon are sent to the asylum at New Westminster, 
British Columbia ; those from the Northwest Territory to the asy- 
lums of Alberta and Saskatchewan. The daily maintenance charge 
paid by the Dominion government for their keep is $1 per patient. 



IV. 

SYSTEM OF CARE IN THE PROVINCES OF CANADA, 

AND GOVERNMENT AND INSPECTION OF 

PROVINCIAL INSTITUTIONS. 

Excepting as regards the Province of Quebec, an account of 
which is given in a separate chapter,' the methods of care of the 
insane in the various provinces which go to make up the Dominion 
of Canada are, in a large measure, similar in character. These 
various methods are gone into in detail in the chapters pertaining 
to the individual histories of Canadian institutions which are 
published in a subsequent volume. In the following pages are 
given brief outlines only of the methods of care, and of the 
government and inspection of provincial institutions. 

In New Brunswick, St. John Asylum, which was opened in 
1835, continued under charge of a layman, then the overseer of the 
poor, with a visiting medical of^cer, until 1843. In that year it 
was first styled the Provincial Lunatic Asylum and was placed in 
the care of a board of commissioners, one of whom acted as 
medical superintendent. This board continued in charge until the 
opening of the new asylum in 1848. This new asylum was placed 
under the management of a board of commissioners, consisting 
of not less than five nor more than nine members, appointed by the 
Governor in Council, and who served without compensation. 
Provision was made for a monthly visitation by one or more mem- 
bers, half-yearly visitations by the majority of them, and a yearly 
visitation by the entire board, which had to report to the (iovernor 
in Council. 

The asylum was, from its opening, under the charge of a 
medical superintendent. 

In 1859 the control of the asylum was vested in the Provincial 
Board of Works. In 1861 the internal affairs of the institution 
were transferred to a new commission, consisting of the heads 
of governmental departments. The system then adopted still 

^ " The Contract System of the Care of the Insane in the Province of 
Quebec." 



SYSTEM OF CARE IN THE PROVINCES OF CANADA 459 

remains in vogue, the commissioners retiring with any change of 
government/ 

New Brunswick, since the time of the establishment of its first 
asylum, has declared against the incarceration of lunatics, even 
temporarily, in prisons or poorhouses. The province has recog- 
nized that the insane are wards of the state and has always en- 
deavored to provide for all classes of suflferers from mental 
disease.' 

A custom peculiar to the New Brunswick institution is the col- 
lection of an admission fee of $20, either from relatives or munic- 
ipalities, for every patient received into the hospital. This cus- 
tom has been in force as far back as can be traced, and has become 
so well established that everyone expects to pay it, and there is 
never any objection to its payment. Beyond this payment none 
was made by the municipal authorities, the whole outlay being met 
by the government. To remedy this a law was passed in 1894 to 
charge the counties $1.25 per week each for all harmless patients. 
This law met with violent opposition and became practically a 
dead letter. In consequence a new act was passed in 1913, which 
requires the counties to pay $1 per week per capita for all their 
insane, whether harmless or not, if relatives do not pay this 
amount or more.^ 

The first asylum established for the insane of Ontario was 
opened in January, 1841. It was located in the old York jail, 
w^hich had been abandoned as such, and which had been converted 
into a temporary asylum, under the management of a commission 
of four members, appointed by the Lieutenant Governor; there 
was also a medical superintendent in direct charge of the patients. 

In July, 1843, the original commissioners were, in accordance 
with the provisions of the act of 1839, increased in number to 12. 

In 1846 an additional temporary asylum was established as a 
branch of the original asylum, and under the same management 
in the east wing of the old Parliament buildings in Toronto. 

^ Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." 
Proceedings and Transactions Royal Society of Canada, Second Series, 
Vol. IV, pp. 5-10. 

'Ibid., p. 14. 

^ See " History of the Care of the Insane in New Brunswick " in a subse- 
quent volume. 



460 INSTITUTIONAL CARE OF THE INSANE 

These buildings were abandoned in January, 1850, when the per- 
manent asylum, known as " The Provincial Lunatic Asylum," 
was opened for the reception of the insane of the province. 

Up to 1850, when the temporary asylums were abandoned, 
their condition was far from creditable, a fact in great measure 
due to the changes in management, which occurred with startling 
rapidity/ Mr. J. H. Tuke, who visited the asylum in 1845, made 
the following entry in his diary : ' 

Toronto, September 30, 1845. — Visited the lunatic asylum. It is one of 
the most painful and distressing places I ever visited. The house has a 
terribly dark aspect within and without, and was intended for a prison. 
There were, perhaps, 70 patients, upon whose faces misery, starvation and 
suffering were indelibly impressed. The doctor pursues the exploded 
system of constantly cupping, bleeding, blistering and purging his patients ; 
giving them also the smallest quantity of food, and that of the poorest 
quality. No meat is allowed — I left the place sickened with disgust, and 
could hardly sleep at night, as the images of the suffering patients kept 
floating before my mind's eye in all the horrors of the revolting scenes I 
had witnessed. 

The same may be said of the new institution up to the time Dr. 
Workman became superintendent in 1853. 
According to Dr. Burgess : '' 

Much that is best in the present system of caring for the insane in 
Canada can be traced to the wisdom of this accomplished gentleman, 
fittingly styled by Dr. D. Hack Tuke "the Nestor of Canadian alienists." 
Under his regime mere custodial care, with more or less neglect and cruelty, 
gave place to a system of kindness and scientific treatment. 

On June 20, 1853, the old board of 12 directors was replaced 
by a visiting committee. The act authorizing this change also 
vested the property in the Crown ; placed the appointment of the 
medical superintendent, as well as that of the bursar, in the hands 
of the government, and gave to the su})erintendent power to hire 
and dismiss all officers and servants other than the bursar. 

This new system of control remained in force up to December, 
1859, when, under provision of the Consolidated Statutes of 

* Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." 
Proceedings and Transactions Royal Society of Canada, Second Series, 
Vol. IV, p. 22. 

' Tuke, D. H., M. D. : " The Insane in the United States and Canada." 
London, 1885, p. 214-215. 

' " Canadian Institutions for the Insane." Proceedings and Transactions 
Royal Society of Canada, Second Series, Vol. IV, p. 29. 



SYSTEM OF CARE IN THE PROVINCES OF CANADA 461 

Canada, the visiting committee was superseded by the appoint- 
ment of a board of five inspectors by the legislative assembly.' 

After confederation of the provinces on July i, 1867, the asy- 
lums, with the jails and other public institutions, came under the 
control of the local Legislatures ; in 1868 Ontario adopted the 
present system of direct governmental supervision, through an 
inspector appointed for that purpose.' 

The Legislative Assembly of the Province of Ontario in 1871 
enacted " An Act Respecting Lunatic Asylums and the Custody of 
Insane Persons." ^ 

Under the provisions of this act the public asylums are estab- 
lished and acquired under a grant from the Legislature of the 
province, and are vested in the Crown. The Lieutenant Governor 
has the appointment of the medical superintendent. Among the 
duties of this last-named officer are those of reporting the con- 
dition of the asylum to the Inspector of Prisons and Public Chari- 
ties at each visit, and also of reporting annually to the inspector 
upon the afifairs of the institution. The financial affairs of asy- 
lums are conducted by the bursar, who is appointed by the Lieu- 
tenant Governor. 

The asylums of Ontario are state institutions in the fullest 
sense of the word. In the majority of cases the patients are main- 
tained entirely at government expense ; in other cases, where they 
are able to do so without hardship, the friends are charged a rate 
that covers the bare cost of keep." 

A striking feature of the early history of the asylums in the 
Province of Ontario is the extent to which the acquisition of 
" branch asylums " developed. These in most cases were designed 
to relieve overcrowding without the expense of adding additional 
buildings to the original asylum. In general they occupied aban- 
doned buildings, unsuited in every way for asylum purposes, and 
were in some cases put under the charge of an assistant physician. 
Ultimately they were abandoned or became in themselves the 
nuclei of independent institutions. 

^Ibid., p. 31. 'Ibid., p 33. 

' Tuke, D. Hack : " The Insane in the United States and Canada." 
London, 1885, p. 209. 

* Burgess, T. T. W., M. D. : American Journal of Insanity, Vol. LXII, 
p. 14. 



462 INSTITUTIONAL CARE OF THE INSANE 

Thus the Toronto Asylum when it opened in 1850 was the con- 
soHdation of three temporary asyhims, maintained in the old jail, 
Parliament building;s, and a Bathhurst Street house respectively. 
To relieve overcrowding', in July, 1856, a building" which had been 
erected as the commencement of the ITniversity of King's College 
was converted into a supplemental asylum. In 1859 the old mili- 
tary barracks at Fort Maiden were converted into another branch 
asylum. This was made an independent asylum in 1861. Yet 
another branch asylum was established at Orillia in 1859,' which 
was continued in operation up to 1870, when it was abandoned on 
the transfer of the patients to the new asylum, then opened at 
London. 

A like situation occurred at Rock wood Asylum in 1885, when 
an old stone building in the City of Kingston, originally erected 
as a Roman Catholic seminary, was rented, renovated and occupied 
by patients of the chronic class. It remained in use up to Feb- 
ruary, 1891, when the opening of the new institution at Mimico 
allowed it to be dispensed with. 

At first the administration of Mimico Asylum was directed 
from the Toronto Asylum, of which it was a branch, known as 
the Mimico Branch Asylum. It was so conducted from its open- 
ing, January, 1890, up to its transformation into an independent 
asylum in November, 1894. 

In Prince Edward Island the administration of the affairs of 
the Asylum for Insane Persons, opened at Charlottetown in 1847, 
was vested in a board of eight trustees. The asylum was under 
the direct charge of a master and matron ; there was in addition a 
medical officer, who visited the institution once or twice a week. 

This arrangement continued until 1874, when a report of the 
grand jury of that year, containing as it did a scathing denuncia- 
tion of the management of the asylum, paved the way for certain 
reforms. The report of the grand jury"" disclosed a condition of 
affairs so repugnant that it is hard to believe that an institution 
so conducted could exist in a civilized community. In a cell below 
the ground, about six by seven feet, they found a young woman 

^ This asylum was again opened in 1876 for the accommodation of 150 
idiots, and continues to care for this class of patients up to the present. 

' See " History of the Care of the Insane in Prince Edward Island " in 
a subsequent volume. 



SYSTEM OF CARE IN THE PROVINCES OF CANADA 463 

entirely naked, beneath some broken, dirty straw. The stench 
was unbearable. In another cell, about the same size, another 
young woman was closely confined. To (luote the report : 

The whole asylum is in one state of filth ; men's rooms and women's 
exhibit an utter absence of the slightest attempt at cleanliness, while the 
stench was such that some of the jury were ill for hours after inhaling it. 

The immediate result of the report was the removal of the 
officers and a change of conditions as far as circumstances would 
permit. The movement thus started led to the passage in 1877 of 
a new lunacy act ' providing for the erection of the Prince Edward 
Island Hospital for the Insane, and the creation of the office of 
medical superintendent. At the same time the Board of Trustees 
was reduced in number to five members, who were to meet quar- 
terly at the hospital, one of them to visit the hospital once a 
week. 

The new hospital was opened on December 10, 1879. ^^ 1889 
the medical superintendent was again made a visiting officer, 
instead of a resident one, and this arrangement has continued in 
force up to the present. 

In 1909 The Provincial Infirmary, known as the Poorhouse, 
was erected on the asylum grounds and placed under the same 
medical supervision. To it are transferred from the hospital 
proper, idiots, imbeciles and dements, provision being made for 
their re-transfer to the hospital by the superintendent if deemed 
necessary. 

This combination of a poorhouse and asylum is a distinctly 
backward step in the care of the insane in Prince Edward Island.' 

Previous to 1858 the pauper lunatics of Nova Scotia were sent 
to the lunatic ward of the Provincial and City Poor's Asylum in 
Halifax, or cared for at home in what way can be imagined." In 
that year, however, the Provincial Hospital for the Insane was 
opened for the reception of patients, its object being defined as 
" the most humane and enlightened curative treatment of the 
insane of this province." This institution, now the Halifax City 

^ 38 Victoria, Cap. 4. 

^ Burgess, T. J. W., M. D. : " Canadian Institutions for the Insane." 
Proceedings and Transactions Royal Society of Canada, Second Series, 
Vol. IV, p. 100. 

''Ibid., p. 100. 



464 INSTITUTIONAL CARE OF THE INSANE 

Asylum and Poorhouse, was supported jointly by the province and 
city. It received paupers from all parts of the province, and had 
two wards for lunatics/ 

The management of the hospital was at first vested in a body 
of commissioners, nine in number, appointed by the Governor in 
Council. There was in addition a medical superintendent in 
direct charge of the patients. 

Insane transient paupers were authorized to be received at 
provincial expense, but only after the commissioners had been 
satisfied by affidavit that such persons were not properly charge- 
able to any township or county of the province.* 

In i860 the control of the hospital was vested in the Board of 
Public Works. In 1867 a board of three commissioners was 
appointed to replace the Board of Works in the general super- 
vision of the hospital, part of their duty being to visit it weekly. 
In 1878 this board gave place to a Board of Public Charities, con- 
sisting of five members. Of the new board the Commissioner of 
Works and Mines was chairman and the Mayor of Halifax an 
ex-oMcio member." In 1886 the government abolished the Board 
of Public Charities and made the Commissioner of Public Works 
and Mines the sole authority. This arrangement is still in vogue, 
but has been supplemented by the appointment of an Inspector of 
Public Charities, making the system practically identical with that 
of Ontario.' 

The maintenance of the hospital is undertaken by the govern- 
ment, the lands and buildings being provided by the province. The 
municipalities are charged at the rate of $3.50 per capita per 
week for the patients they send in. 

The institution is the only one of its kind in the province, but 
since 1886 a few counties have erected county asylums, and a num- 
ber combined county asylums and poorhouses. To these can be 
transferred the harmless insane from the provincial hospital, and 
to them can be sent direct idiots, non-violent epileptics and cases 
of chronic insanity refused admission there upon statutory 
grounds." 

Up to 1873 no act had been passed for the founding or regula- 
tion of asylums in British Columbia, but in that year an act known 

^ Ibid., p. loi. ^ Ibid., p. 103. 'Ibid., p. 104. * Ibid., p. 105. 

° See " The Care of the Insane in Nova Scotia " in a subsequent volume. 



SYSTEM OF CARE IN THE PROVINCES OF CANADA 465 

as the Insane Asylums Act came into force.' It fixed the title 
of the new establishment as " Asylum for the Insane, British 
Columbia," and placed it in the charge of the Provincial Secretary, 
under whose department it has remained ever since. The direct 
management of the asylum was in the hands of a non-resident 
" medical superintendent " and a " superintendent of the asylum," 
the latter a resident layman, whose duty it was to look after the 
internal economy and discipline.' The act of 1873 was amended 
in 1893,' and, together with the amendment, repealed in 1897, a 
new act, the Hospital for Insane Act,' replacing it. 

In 1885 the hospital was placed in charge of a medical super- 
intendent. 

The system of management of the Public Hospital for the 
Insane, New Westminster, as well as the British Columbia Mental 
Hospital at Coquitlam, are under the control of the Provincial 
Secretary. 

The system of management in the Manitoba asylums is similar 
to that used in Ontario, they being under the supervision of an 
inspector, who is directly responsible to the government.' In the 
case of destitute patients the province pays all expenses. All 
treaty Indians are paid for by the dominion government. 

By an act of the Legislature of the Province of Alberta, passed 
in 1907, and entitled the Insanity Act, the insane and their affairs 
were placed in charge of the department of the Attorney General." 

An act of the Legislature of Saskatchewan of 1906, known as 
the Attorney General's Act,' placed in the Attorney General's de- 
partment the superintendence of prisons, asylums, houses of cor- 
rection and other places of confinement within the province, also 
the inspection of all certificates bearing upon the admission and 
discharge of lunatics to and from asylums. To the department of 
public works by this act was deputed the construction, charge and 
direction of all such government buildings. The maintenance of all 

' See " The Care of the Insane in British Columbia " in a subsequent 
volume. 
' Ibid. 

' 56 Victoria, Chapter 18. 
*6o Victoria, Chapter 17. 

^ See " The Care of the Insane in Manitoba " in a subsequent volume. 
' Statutes of Alberta, 7th ed., VII, Cap. 7. 
'Revised Statutes of Saskatchewan, 1906, Cap. 22, Sec. i. 



466 INSTITUTIONAL CARE OF THE INSANE 

pauper lunatics was made a provincial burden by the same en- 
actment. 

The care of the insane in the Yukon and Northwest Territories 
and their conveyance to an institution in one of the neighboring 
provinces falls to the lot of the Royal Northwest Mounted Police, 
there being no asylum in these districts. The daily maintenance 
charge paid by the Dominion Government for the care of the 
insane of these territories is $1 per day per capita.* 

* See " The Care of the Insane in the Yukon and Northwest Territories " 
in a subsequent volume. 



V. 

THE CONTRACT SYSTEM IN THE PROVINCE OF 

QUEBEC. 

At the present time the insane of the Province of Quebec are 
cared for in five hospitals, four of which, namely, The Quebec 
Lunatic Asylum, known as Beauport Asylum ; L'Hospice St. 
Jean de Dieu, known as Longue Pointe Asylum ; L'Hospice St. 
Julian, and Baie St. Paul Asylum, are proprietary institutions, 
owned by and under the charge of the Sisters of Charity. The 
fifth hospital is the Protestant Hospital for the Insane, commonly 
called Verdun Hospital, which is a corporate charitable institution, 
erected in large measure by a number of Protestant citizens of 
Montreal. The leading- clause in its charter of constitution stipu- 
lates that all monies received by the corporation, from whatever 
source, shall be expended upon the institution and its inmates. 

All public patients in the Province of Quebec are cared for in 
these five institutions, under contract with the government for 
the sum of from $100 to $142 per year. In addition there have 
been at times grants made by the government to dififerent insti- 
tutions. In the latter case the asylums receiving such grants are 
under the control of the government ; all other asylums are under 
its supervision only. The Lieutenant Governor appoints a medical 
superintendent for each asylum under a contract with the govern- 
ment ; he also appoints in addition an assistant medical superin- 
tendent and one or two house physicians for the three asylums, 
known as St. Jean de Dieu, Verdun and Beauport. The salaries 
of these ofificials are paid by the government. 

The duties of the officers thus appointed are defined by law. 
Briefly stated they are as follows : 

The medical superintendent supervises the admission and dis- 
charge of patients; he controls the medical service, the classifica- 
tion of patients and their treatment ; he formulates all rules and 
regulations for the medical, moral and physical treatment of 
patients ; he may require proprietors to dismiss nurses or guardians 
for incompetence or insubordination ; he is required to make an 
annual report to the Provincial Secretary respecting the patients 
under his care. 



468 INSTITUTIONAL CARE OF THE INSANE 

The assistant medical superintendent exercises the powers of 
the superintendent in the event of his absence or inabiHty to 
serve. The house physicians are required to devote their whole 
time to the service of their patients and to reside near the asylum. 

The above regulations, while not overcoming the errors of the 
" farming-out system" of the care of the insane, have served in 
a measure to correct some of the most glaring evils consequent to 
such arrangement. How many and great these evils were, a brief 
survey of the history of the efforts made to correct the system 
will serve to indicate. 

Of Beauport Asylum, in 1869, Dr. James R. DeWolf states:' 

Next to the Toronto Asylum in point of seniority is that at Beauport, 
near Quebec, a private institution, in which there are 600 patients. A large 
majority of these are supported by the Province of Quebec, the proprietors 
receiving a liberal allowance for their maintenance. Although the present 
buildings are comparatively new, the inmates are crowded, while the 
ventilation is greatly defective. Many of the single dormitories are prison- 
like in the extreme, having no windows, but opening into a corridor by a 
door with an open space above. This most objectionable arrangement is 
all the less excusable, since the proprietors are themselves medical men.' 

A still darker picture is that given 15 years later by Dr. D. Hack 
Tuke.' Speaking of the same institution he states : 

But it is needless to describe in more detail an institution which, however 
willingly I may praise where praise is due, is so radically defective in 
structure and so fundamentally different from any well-conducted institu- 
tion of the present day, in the matter of moral, to say nothing of medical 
treatment, that no tinkering of the present system will ever meet the require- 
ments of humanity and science; and again, the proprietors receive $11 per 
head per month for maintenance and clothing. This system involves the 
probability of patients being sacrificed to the interests of the proprietors. 

Speaking of Longue Pointe Asylum he writes: 

It is impossible to convey an adequate idea of the condition of the patients 
confined in the gallery in the roof and in the basement of this asylum. They 
constitute the refractory class — acute and chronic maniacs. They and the 
accommodation which has hitherto been provided for them must be seen 
to be fully realized. To anyone accustomed to a well-ordered institution 
for the insane the spectacle is one of the most painful character. In the 

' Journal of Mental Science, Vol. XIV, p. 466. 

' Beauport did not come under the control of the Sisters of Charity 
until 1893. 

' " The Insane in the United States and Canada," H. K. Lewis, London, 
i88.q. 



CONTRACT SYSTEM IN PROVINCE OF QUEBEC 469 

course of seven and thirty years I have visited a large number of asylums 
in Europe, but I have rarely, if ever, seen anything more depressing than 
the conditon of the patients in those portions of the asylum at Longue 
Pointe to which I now refer. 

And further, after describing conditions in detail: 

Into this human menagerie, what ray of hope can ever enter? 

And again : 

But it is amazing to reflect that although the superiority of the humane 
mode of treating the insane inaugurated nearly a century ago has been 
again and again demonstrated, and has been widely adopted throughout 
the civilized world, a colony of England, so remarkable for its progress and 
intelligence as Canada, can present such a spectacle as that I have so 
inadequately described as existing, in the year of grace 1884, in the Montreal 
Asylum. 

At the time of Dr. Ttike's report there were three inspectors of 
the asylums and prisons of the province, whose duty it was to 
report to the Provincial Secretary, to whose department the insti- 
tutions were subject. The inspectors were supposed to visit the 
different institutions three times each year. The grand jury also 
was empowered to visit the asylums and make presentment to the 
court in regard to their condition. There was likewise a visiting 
physician, appointed and paid by the government. It seems from 
Dr. Tuke's report ^ that the duties of the inspectors and the grand 
jury were performed in a purely formal manner, and that the 
authority of the visiting physician was practically nil. It is true 
that an act of the Quebec Legislature, passed in June, 1884, ex- 
tended and enforced the authority of this officer, but it had little 
or no apparent effect in the conduct of the institution. 

Following the visit of Dr. Tuke to the Quebec asylums, a meet- 
ing of the Medico-Chirurgical Society of Montreal was held, 
November 7, 1884, when the following resolutions were unani- 
mously passed : ^ 

1. That this society has every reason to believe that the statements 
contained in the report of Dr. D. Hack Tuke, of London, England, upon 
our provincial lunatic asylums, are, in every material respect, true and well 
founded. 

2. That these statements show a most lamentable state of things as 
regards the general, and especially the medical, management of these 
institutions. 

^ Ibid., p. 200. 

* Canada Medical and Surgical Journal, Nov., 1884. 

37 



470 INSTITUTIONAL CARE OF THE INSANE 

3. That it appears to this society to be the imperative duty of the 
provincial government to institute a thorough investigation by competent 
persons into the entire system of management of the insane poor in this 
province. 

4. That the " farming " or " contract " system, either by private individuals 
or by private corporations, has been everywhere practically abandoned, 
as being prejudicial to the best interests of the insane and producing the 
minimum of cures. 

5. That in the opinion of this society all establishments for the treat- 
ment of the insane should be owned, directed, controlled and supervised 
by the government itself, without the intervention of any intermediate 
party. 

6. That the degree of restraint known to be employed in our provincial 
asylums is, according to the views of the best modern authorities, excessive. 
That the ablest European, American and also Canadian alienists have almost 
entirely given up any method of mechanical restraint. That these facts call 
urgently, in the name of humanity, for reform in this direction in our 
provincial asylums. 

The resolutions closed with a statement supporting Dr. Tuke's 
report that the hands of the visiting physician, Dr. Henry Howard, 
were tied and that he could not be held responsible for the con- 
ditions which existed. 

While the report as given above indicates that the medical prac- 
titioners of the Province of Quebec were eager and willing that 
the abuses of the " contract system " be remedied, and that the 
province should assume the obligation of the care of its insane, 
nothing was done to remedy existing conditions. 

One outcome of the agitation, however, was the establishment 
of the Protestant Hospital for the Insane, an incorporated chari- 
table institution, which, while paid by the government for the 
maintenance of public Protestant patients, is safeguarded by the 
leading clause of its constitution, as already mentioned.' 

Ten years later a further effort was made on behalf of the 
insane of the province which resulted in the passage of an act ' 
which gave to the government greater powers of supervision and 
control in regard to the lunatic asylums. These powers are those 
in force at the present and have already been set forth in the 
preceding pages of this article. 



' Burgess, Dr. T. J. W. : American Journal of Insanity, Vol. LXII, p. 
' R. S. Q. 3183 ; 57 V. c. 22, SI et seq. 



10. 



CONTRACT SYSTEM IN PROVINCE OF QUEBEC 47I 

A statement of the care of the insane in Quebec would not be 
complete without mention of St. Johns Asylum/ the only govern- 
ment institution for the care of the insane ever established in the 
province. This asylum was opened in 1861 and closed in 1875. 
Its history adds nothing to the credit of the province, the buildings 
being wretchedly insufficient in every particular for the needs of 
the insane. The cost of maintenance was excessive, being annually 
considerably over $200 per capita. It is only fair to state in this 
connection that the sum paid the Sisters of Charity for the sup- 
port of the public patients at Longue Pointe was, as late as 1875, 
but $100 per annum, an utterly inadequate amount for proper care 
and treatment. 

Before Quebec can be counted in the foremost line, where it 
ought to be, the province must own as well as supervise its insti- 
tutions for the dependent insane.' 

' See " History of St. Johns Asylum " in a subsequent volume. 

^ Burgess, Dr. T. J. W. : American Journal of Insanity, Vol. LXII, p. 10. 



VI. 

IMMIGRATION AND THE CARE OF THE INSANE IN 

CANADA. 

The 20th century practically marks the beginning of real immi- 
gration to Canada. A reference to the census of population dur- 
ing a period of 40 years, prior to 1900, shows that Canada scarcely 
maintained an increase throughout the census periods equivalent 
to a natural increase. This was due in part to the enormous immi- 
gration to the American prairies and to the delay in opening to 
immigration the colder prairies of the Canadian Northwest. 
There had been an Immigration Act in force, practically since 
the confederation in 1867, but its provisions with regard to the 
examination and rejection of immigrants, if existing at all, were 
imperfect. Two clauses were added to this act in 1902, making 
it possible to reject at the seaports any immigrants suffering from 
any "loathsome, contagious or infectious disease, or which may 
become dangerous to public health." Under the act thus amended, 
medical immigration inspection began in 1903. In 1904 Dr. Peter 
H. Bryce was appointed chief medical officer of the service. After 
observing the operations of the act during 1904 and 1905, with 
the assistance of the legal department he re-wrote the Immigration 
Act practically in its present form, and it was made a law in 1906. 
This act was amended in 1910 and again on April 4, 191 1. This 
last is the act which is in force at the present time (1915). 

Section 3 of this act provides that no immigrant, passenger, or 
other person, unless he is a Canadian citizen or has Canadian 
domicile, shall be permitted to land in Canada, or in case of having 
landed in or entered Canada shall be permitted to remain therein 
who belongs to certain prohibited classes, which this section of 
the act enumerates. Among the prohibited classes are: (a) 
Idiots, imbeciles, feeble-minded persons, epileptics, insane persons 
and persons who have been insane within a period of five years 
previous, (b) Persons afifected with any loathsome disease, or 
with a disease which is contagious or infectious, or which may 
become dangerous to the public health, whether such persons 
intend to settle in Canada or only to pass through Canada in 
transit to some other country. In the latter case provision is made 
for medical treatment provided that such disease is curable within 



IMMIGRATION AND CARE OF INSANE IN CANADA 473 

a reasonably short time, (c) Immigrants who are dumb, bHnd, 
or otherwise physically defective, unless they are not liable to 
become a public chars^e. (d) Persons who have been convicted 
of any crime involving moral turpitude, (e) Prostitutes, women 
coming to Canada for immoral purposes and persons living on the 
avails of prostitution, (f) F'ersons who procure or attempt to 
bring into Canada prostitutes or women for other immoral pur- 
poses, (g) Professional beggars, or vagrants, or persons likely 
to become a public charge. In addition there are sub-sections (h) 
and (i) which refer to charity immigrants and persons not com- 
plying with regulations. 

Section 5 provides for the appointment by the Governor in 
Council of a Superintendent of Immigration, Commissioners of 
Immigration, and such other officers as are deemed necessary for 
carrying out the provisions of the act. 

Section 13 provides for the appointment of a permanent Board 
of Inquiry for the summary determination of the condition of all 
cases of immigrants or passengers seeking to enter Canada or 
detained for any cause under the act. 

Section 18 provides that there shall be no appeal from the 
decision of such Board of Inquiry as to the rejection and deporta- 
tion of immigrants, or other persons seeking to land in Canada, 
when such decision is based upon a certificate of the examining 
medical officer to the efifect that such persons are afflicted with 
any loathsome disease, or with a disease which may become dan- 
gerous to the public health, or that they come within any of the 
following prohibited classes, namely, idiots, imbeciles, feeble- 
minded persons, epileptics and insane persons. 

Section 28 provides that the medical officers appointed under 
the act shall make a physical and mental examination of all immi- 
grants and passengers seeking to land in Canada. 

Section 30 provides that every transportation company shall, for 
the purpose of the act, be considered as one with any transporta- 
tion company with which it co-operates or makes or affords con- 
nection, whether in Canada or not and whether under the same 
management or not, and shall be liable for any ofifense against the 
act by any company with which it co-operates or makes connection. 

Section 33, sub-section 5, provides that an order for deporta- 
tion shall be made in a form prescribed in the act, and that a copy 
of the order shall be delivered to the person deported, and to 



474 INSTITUTIONAL CARE OF THE INSANE 

the master or owner of the ship or to the local agent or other 
officials of the transportation company hy which such person was 
brought to Canada ; and such person shall thereupon be deported 
by such company subject to any appeal which may have been 
entered under Section 19 of the act. 

Sub-section 8 provides for a penalty for landing or attempting 
to land any prohibited immigrant of a fine of not more than 
$500 and not less than $50 for each prohibited immigrant. 

Section 34 provides for the medical treatment of any person 
seeking to enter Canada or who has been rejected or is detained 
for any purpose under the act, who is suffering from sickness or 
physical or mental disability, such treatment to be given aboard 
ship or in an immigrant station or in a suitable hospital as the 
officers in charge may decide. In the case where the transporta- 
tion company which brought such person to Canada failed to exer- 
cise proper vigilance in so doing, then the cost of such medical 
attention and maintenance shall be paid by such transportation 
company. This applies also to the cost of attendant to such 
person, if such be required during the person's detention, or in 
case of deportation, then the cost of the accompanier of such per- 
son to his port of embarkation from Canada. 

Section 40 provides for the deportation of any person who 
within three years after landing in Canada has been convicted of a 
criminal offense in Canada, or has become a prostitute, or by com- 
mon repute has become a person living on the avails of prostitu- 
tion, or has become a professional beggar or a public charge, or 
an inmate of a penitentiary, gaol, reformatory, prison, hospital, 
insane hospital or public charitable institution.^ In such case 
it shall be the duty of any officer cognizant thereof, and the duty 
of the clerk, secretary or other official of any municipality in 
Canada wherein such persons may be, to forthwith send a written 
complaint thereof to the Minister or Superintendent of Immi- 
gration, giving full particulars. 

Section 45 provides for the deportation by vessel or train at 
the expense of the transportation company of any person coming 
within the prohibited classes, such deportation being to the place 

'Any person of the undesirable classes previously enumerated can be 
deported at any time zvithin a period of three years after arrival in the 
dominion. 



IMMIGRATION AND CARE OF INSANE IN CANADA 475 

in the country whence he was brought or to the place of his citizen- 
ship, as the case may be. 

Section 47 provides regulations for the proper treatment of 
persons so deported while awaiting and during deportation. 

Section 49 provides for a manifest to be delivered by the master 
of every vessel arriving at any port of entry in Canada, which 
shall state the name and age of every passenger on such vessel who 
is insane, idiotic, epileptic, dumb, blind or infirm, or suffering from 
any disease or injury under the act. 

Sections 76, yy and 78 provide for prosecutions, procedure and 
penalties for violations of any provisions of the act. 

Clause 40, which places the duty of deporting undesirable classes 
upon the secretary or clerk of every municipality of Canada, is 
peculiar to the Canada Immigration Act, and has been of great 
assistance in the prevention of the congestion of institutions with 
undesirables. 

The following tables, furnished through the kindness of Dr. 
Peter H. Br>'ce, will serve to show the increase in immigration 
subsequent to 1900, as well as the number of immigrants rejected 
at the seaport or afterwards deported on account of some mental 
infirmity. The history of the rejections and deportations as seen 
in the tables illustrates in a large measure the workings of the 
Immigration Act. 

Number of Rejections at Port of Entry. 



Total 
immigration. 

1900-01 49,149 

1901-02 67,379 

1902-03 128.364 

1903-04 130,331 

1904-05 146,266 

1905-06 189,064 

9 months ending March 

1907 124,667 

1907-08 262,469 

1908-09 146,908 

1909-10 208,794 

1910-11 311,084 

1911-12 354,237 

1912-13 402,432 

Total 2,521,144 118 40 171 



insanity. 


Epilepsy. 


Imbeciles- 

mentally 

weak, 

etc. 




















I 





I 


5 


9 





3 


2 


4 


II 


5 


II 


8 


3 


5 


19 


4 


12 


13 





28 


IS 


4 


31 


5 


8 


27 


15 


5 


27 


23 





25 



476 INSTITUTIONAL CARE OF THE INSANE 

Number of Deports After Admission. 

Imbeciles, 

mentally 

Insanity. Epilepsy. weak, etc. 

1902-03 I 6 8 

1903-04 5 4 9 

1904-05 5 2 7 

1905-06 12 6 18 

9 months ending March 

1907 SZ 6 22 

1907-08 110 15 45 

1908-09 1 13 22 36 

1909-10 95 8 12 

1910-11 121 10 17 

1911-12 133 8 10 

Total 868 97 193 

Despite the provisions of the Immigration Law, the foreign 
born form a large part of the population of the insane hospitals of 
the provinces. This has been due in part to the fact that the 
present deportation law is of recent efifect, and in part to the fact 
that the system of inspection at the ports of arrival is not as com- 
plete as it should be. 

According to Dr. T. J. W. Burgess : ' 

Unhappily quite a large number of the immigrants brought to us are of 
a low standard of mentality, some of them even having been inmates of 
asylums before coming to this country. Such a condition amid new environ- 
ments and under new conditions of existence is almost sure to lead to 
mental strain and insanity. The result is that these incompetents, many of 
them consisting of the scum and dregs of an overcrowded European popula- 
tion, are crowding our provincial hospitals, especially those of Ontario, 
Manitoba and British Columbia, to which province immigration has been 
largest, and those contiguous to large seaports, such as Montreal. Most of 
our institutions have a larger percentage of foreigners than is found among 
the native population, and while the greater number of the foreign-born 
inmates are legitimately there, having broken down mentally after they 
had earned a residence, there is in every asylum a proportion who should 
never have been brought to our shores. Some of these have come of 
their own accord, but it is evident from the statements of the patients 
themselves that in certain cases parochial boards, benevolent societies, 
municipalities, and even relatives, have sent out persons simply as the 
cheapest way of getting rid of them. 

In Ontario the foreign-born population of the province was, 
in 1907, about 20 j^er cent of the total ; that year, however, it fur- 

' .American Journal of Insanity, Vol. LXII, p. 19. 



IMMIGRATION AND CARE OF INSANE IN CANADA 477 

nished 38 per cent of the gaol commitments, and in the Central 
Prison, Toronto, 41 per cent of the prisoners admitted were 
foreigners/ 

In Toronto Hospital for Insane, of 422 admissions during 
1908, 50 per cent were foreign-born, and of these the great 
majority were recent arrivals/ During the year 1903 there were 
admitted to Canadian asylums 2213 insane persons. Of this 
number 487 or 22 per cent were of foreign birth. At Verdun 
Hospital, of the 2048 patients received up to 1905, 40 per cent were 
of foreign birth." 

The passage of the more rigorous immigration laws as already 
noted, and a higher degree of care exercised at the ports of entry 
by those appointed to carry out the provisions of the law, have in 
the last few years been instrumental in mitigating the evils con- 
sequent to the introduction of defective aliens. That this system 
of care will continue to grow and will eventually prevent Canada 
from being a " dumping ground " for the mentally unfit of 
Europe cannot be doubted. 

^ American Journal of Insanity, Vol. LXV, p. 186. 

'Ibid. 

^ Burgess, Dr. T. J. W. : American Journal of Insanity, Vol. LXII, p. 22. 



VII. 

CENSUS OF THE INSANE IN CANADA/ 

The Census Department at Ottawa is unable to furnish figures 
relative to the insane in Canada prior to confederation, which 
took place in 1867. The earliest statistics relative to the insane 
are found in the census of 1871. 

In the four provinces which constituted the Dominion of Canada 
at that time the insane were numbered as follows: Ontario, 4081 ; 
Quebec, 3300; New Brunswick, 788; Nova Scotia, 1254. Total, 

9423- 

The latest official publication containing figures of the insane 
and defectives is the Government Census for 191 1, when the 
insane in Canada by provinces were as follows : 

Alberta 43 

British Columbia 713 

Manitoba 1 156 

New Brunswick 500 

Nova Scotia loi i 

Ontario 6175 

Prince Edward Island 275 

Quebec 4772 

Saskatchewan 53 

Yukon 2 

Northwest Territories 2 

Total 14702 

The idiots in 191 1 by provinces were as follows: 

Alberta 91 

British Columbia 96 

Manitoba 190 

New Brunswick 443 

Nova Scotia 644. 

Ontario 2656 

Prince Edward Island 1 16 

Quebec 1727 

Saskatchewan 113 

Yukon o 

Northwest Territories 1 1 

Total 6087 

* From information furnished by C. A. Porteous, M. D., Montreal, 
Quebec. 



CENSUS OF THE INSANE IN CANADA 479 

The above figures include all the insane and idiots in the coun- 
try, that is, those in institutions and those outside. 

The insane and defective institutional population in Canada in 
1912-1913 consisted of the following figures by provinces: 

Alberta ( 1913) 287 

British Columbia ( 1912) 822 

Manitoba ( 1913) 1081 

New Brunswick (1913) 600 

Nova Scotia ( 1912-13) 454 

Ontario ( 1913) 6931 

Prince Edward Island (1913) 270 

Quebec ( 1912-13) 4370 

Total 1481S 



VIII. 

THE CHINESE AND JAPANESE IN INSTITUTIONS 

IN BRITISH COLUMBIA BETWEEN THE YEARS 

1871 AND 1913. 

During the years mentioned 228 Chinese were admitted to insti- 
tutions for the insane in British Columbia as follows : In 1872, i ; 
1875, 2; 1876, 2; 1877, I ; 1878, 2; 1880, 4; 1881, I ; 1882, I ; 1884, 
i; 1885, 4; 1886, 5; 1887, 6; 1888, 5; 1889, 9; 1890, 5; 1891, 3; 
1892, 4; 1893, 2; 1894, 5; 1895, 6; 1896, 2; 1897, 4; 1898, 10; 
1899, 2; 1900, 8; 1901, 4; 1902, 9; 1903, 15; 1904, 12; 1905, 10; 
1906, 10; 1907, 22; 1908, 9; 1909, 15; 1910, 4; 1911, 6; 1912, 6; 
August, 191 3, II. Total, 228. 

Japanese. — Between 1894 and 19 13 54 Japanese were admitted 
to institutions for the insane in British Columbia as follows : 
1894, I ; 1895, I ; 1900, 2 ; 1901, 4 ; 1902, 4 ; 1903, 4 ; 1904, 2 ; 1905, 
i; 1906, 5; 1907, 4; 1908, 8; 1909, 7; 1910, 6; 191 1, 4; 1912, 2. 
Total, 54. 



IX. 

DOROTHEA L. DIX AND CANADIAN INSTITUTIONS. 

As has been noted in a previous chapter^ Dorothea Lynde Dix, 
not content with her labors in behalf of the insane in the United 
States, extended her philanthropic efforts to other countries. In 
the year 1848 she visited St. Johns, Newfoundland, and becoming 
interested in the efforts then being made by Dr. Henry Hunt Stabb 
to induce the government of the colony to found a permanent asy- 
lum for the insane of the island, she gave a personal donation of 
iicxD and collected other subscriptions from abroad. But she did 
more than make a material contribution and secure others ; her 
enthusiasm, her determination and efforts to aid the suffering 
insane as well as the poor life savers of Sable Island gave a new 
life and purpose to the movement for better care of the insane in 
Newfoundland, with the result that a well-equipped hospital was 
opened in 1855.^ 

As far as can be learned, the only one of the British North 
American colonies to which Miss Dix devoted especial attention 
was Nova Scotia. On January 21, 1850, she presented to the 
Legislative Assembly of the province and its dependencies a 
memorial praying for the immediate erection of an insane hospital 
to provide for the rapidly increasing number of insane of all 
classes, for whom no provision had as yet been made by the colony. 
Miss Dix's arguments, proving the crying necessity for the erec- 
tion of an insane hospital, were supported by a formidable array 
of facts and figures gathered from various sources and countries, 
as well as a plain recital of the then deplorable condition of the 
insane in Nova Scotia. This memorial is given in full in the 
succeeding Appendix, as being of interest in this connection, 
as well as showing the methods employed by Miss Dix in forcing 
her views and desires on a legislative assembly. 

The Province of Nova Scotia bears the further honor of having 
had the site of its hospital selected by Miss Dix. She took an 
active part in determining various questions connected with the 

' Dorothea Lynde Di.x, Ch. III. 

^ American Journal of Insanity, Vol. L, p. 130. 



482 INSTITUTIONAL CARE OF THE INSANE 

erection of the buildings. As an added mark of her sympathy 
toward the movement Miss Dix gave a collection of pictures to 
ornament the hospital walls. The hospital was finally opened for 
the reception of patients on the 26th of December, 1857.^ 

A portrait of Miss Dix is in possession of the hospital as a 
memorial of the invaluable aid given by her to the cause of the 
insane of Nova Scotia. 



APPENDIX. 

Appendix of Journals of House of Assembly, Nova Scotia, 1850. 

No. 18. 

MEMORIAL TO THE HONORABLE THE LEGISLATIVE ASSEMBLY OF THE PROVINCE 
OF NOVA SCOTIA AND ITS DEPENDENCIES. 

Gentlemen : Your memorialist respectfully asks attention in your legis- 
lative capacity to a subject embracing the welfare of a numerous and 
fast-increasing class of your fellow-citizens who, through want of appro- 
priate care under the access of a terrible malady, are in many instances 
suffering severe hardships and aggravated miseries, and who are not only 
in bondage to a disqualifying physical illness preventing the right use of 
those functions through which the mind finds expression, but in not un- 
frequent cases are subject to the outward bondage of cords and straps, 
chains and fetters ; incarcerated in filthy, unventilated apartments, cold, 
comfortless huts and cabins, and in dreary cells and dungeons; not seldom 
fed and sheltered with less care than the brutes, and pariah-like, cast beyond 
the pale of respect, affection and sympathy. 

I refer to the insane of all classes and ages, and of both sexes, numbered 
now by hundreds, in the Province of Nova Scotia and its dependencies. 

I am aware that this subject, appealing to your humane sensibilities and 
your judgment, is not now for the first time presented for your considera- 
tion ; that the just claims of the afflicted do not now for the first time 
demand legislative action and executive sanction in your country. 

I have seen that so early as February, 1846, a commission designated 
under the authority of His Excellency, the late Lieutenant Governor, Vis- 
count Falkland, and created in accordance with a request emanating from 
the House of Assembly, communicated a comprehensive and able report 
in favor of establishing a hospital for the relief and cure of the insane 
in the province, etc. And, further, it will be recollected that His Excellency, 
Viscount Falkland, in conformity with a resolution of the House of 
Assembly, resulting from facts communicated in the above named report, 
appointed a second commission, consisting of five competent members, viz : 
The Hon. Hugh Bell, John E. Fairbanks, Alexander Sawers, A. M. Uniacke, 

* See "History of the Nova Scotia Hospital, Halifax," in a subsequent 
volume. 



DOROTHEA L. DIX AND CANADIAN INSTITUTIONS 483 

and Charles Twining, whose duty it was made to determine the most 
suitable site in the province for the erection of a lunatic asylum, and for 
ascertaining the probable expense of founding and sustaining such an 
establishment, and to report the same to the House during the session 
next ensuing, together with approved plans and specifications. 

A special report (see House Journal, Appendix No. 11, January, 1847), 
based upon inquiries and estimates conducted with good judgment and 
fidelity to the cause, was communicated to His Excellency, Sir John Harvey, 
and by his command transmitted to the Legislature. This document bears 
date January i, 1847, but it does not appear that any measures have been 
seriously proposed and supported for assuring the result recommended 
and urged by the commission, and which was earnestly represented as of 
great necessity. 

I find, it is true, in a volume of your acts, a series of documents bearing 
the date severally, January 21, 1847, and from which I ask permission 
to make full extracts of such passages as bear upon the subject in question. 
In the opening speech before the Provincial Parliament, His Excellency, 
Sir John Harvey, in a manner which illustrates at once his good judg- 
ment and humane disposition, calls attention to the obligation of providing 
suitably for the insane, as follows : 

"There is another matter which has constituted to me a subject of the 
most painful interest in all the colonies with which I have hitherto been 
connected, and which presents itself to me in a no less distressing aspect 
in this. I allude to the absence of suitable arrangements for the reception 
and treatment, with a view to relief or cure, of that class of unhappy beings 
which I grieve to believe is rapidly increasing in these colonies, owing to 
the causes to which I have adverted, viz : the want of those means of 
effectual application to the disease in its incipient stages which I regard 
as the solemn duty of the legislature of every colony to provide for its 
pauper lunatics. I accordingly earnestly recommend this subject to your 
serious and compassionate consideration, in connection with a very able 
and satisfactory report, which will be laid before you, from the commis- 
sioners appointed by my predecessor in the administration, to select the 
best site for the proposed building." 

To this concise and persuasive appeal, incredible as it may seem, the 
following reply stands recorded ; what meaning the respondents attached 
to it I have in vain endeavored to conjecture: 

" On the last subject of deep and painful interest which Your Excellency 
has been pleased to bring under our notice, we have already, as you are 
probably aware, deliberated, and in the future consideration we shall give 
this interesting subject we shall not fail to be impressed with the perti- 
nency and force of the remarks and reasons by which Your Excellency 
has recommended to our regard the care of the unhappy beings subject to 
the fearful malady to which Your Excellency has adverted." 

It appears that the subject, though of admitted importance, has been 
suffered to slumber ; and, as time wears away, so irrecoverably wears away 
the intellectual capacities of the neglected insane. 



484 INSTITUTIONAL CARE OF THE INSANE 

The history of most of the incurable cases brought to hospitals shows 
that in all probability they might have been restored by timely treatment, 
and it is a fact capable of demonstration, not less in Europe than in 
America, that though the first expense of a patient under hospital treat- 
ment is greater than in an almshouse or at private charge, the ultimate 
expense is much less than if they are suffered to become incurable, and so 
remain a life-long burthen. But pardon the seeming imputation on your 
liberality and justice; this is not a matter of pounds and pence, for who 
will be found skilled to count the cost of care and cure against the value 
of mental health? Who, when bringing this subject home, will be ready 
to determine against a cause founded in the strongest moral obligations of 
man to man, and which presents but one course of correct action — a course 
which admits no compromise, no half measures, no pause, no procrastina- 
tion, a course where afifirmative decision is mental salvation — a course where 
a negative act is mental destruction ! I am sensible that many uninformed 
persons, when the measure for establishing a provincial hospital for the 
insane is first suggested, may oppose the measure on the ground that the 
wants of the country do not at this time demand legislative interposition. 
It will not be a difficult and certainly not an ungrateful task to convince 
all such that their opinions are based in want of correct knowledge ; and 
that inquiry and research will dissipate all their doubts and kindle a desire 
to assist in forwarding a work so urgent, in place of opposing obstacles to 
its speedy accomplishment. 

Let it be understood also that in arriving at convincing facts one need 
not prosecute journeys distant from the seat of government, nor compass 
sea and land to search out the hidden retreats of distress where the hope- 
less and homeless maniac raves, the demented pines, the convulsed epileptic 
shri